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Mishra A, Maiti R, Ramasubbu MK, Srinivasan A. Evaluation of the pharmacodynamic interaction effect of augmentation agents with clozapine in patients with treatment-resistant schizophrenia: A simulation study of clinical data. Psychiatry Res 2024; 338:115989. [PMID: 38824710 DOI: 10.1016/j.psychres.2024.115989] [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: 11/05/2023] [Revised: 05/03/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION The aim of the study was to evaluate interaction effect of various augmentation strategies with clozapine in patients with Treatment-resistant schizophrenia. METHODS Data was extracted for change in positive and negative syndrome scale (PANSS) or brief psychiatric rating scale (BPRS) scores for monotherapy with various antipsychotic agents alone and their combination with clozapine. Individual patient data was generated using simulation of data (factorial trial framework) from published clinical trials for sample sizes from eight to 400 to evaluate interaction effect through linear modeling. Dose equivalents were calculated, and best fit models were determined for simulated data. RESULTS The polynomial model was found to be the best fit for the simulated data to determine interaction effect of combination. The clozapine augmentation with risperidone and ziprasidone was found to be antagonistic, whereas it was additive for haloperidol, aripiprazole, and quetiapine. A synergistic effect was observed for ECT combined with clozapine (Interaction effect: -7.62; p <0.001). A sample size of 250-300 may be sufficient to demonstrate a clinically significant interaction in future trials. CONCLUSION Clozapine may be augmented with electroconvulsive therapy, leading to the enhancement of antipsychotic effect. Though some antipsychotics like aripiprazole demonstrate additive effects, they may also add to the adverse effects.
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Affiliation(s)
- Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Mathan Kumar Ramasubbu
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India.
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2
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Sahib Din J, Navarro Garcia E, Al-Rubaye H, Julian C. Knee Buckling as an Atypical Adverse Effect of Clozapine: A Case Report. Cureus 2024; 16:e55865. [PMID: 38595866 PMCID: PMC11002468 DOI: 10.7759/cureus.55865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Clozapine has become a widely popular and effective medication in the treatment of refractory schizophrenia and refractory bipolar disorder. Although the use of clozapine proves to be an effective resort, it has to be closely monitored due to its narrow therapeutic range and multiple dangerous adverse effects. In rare cases, clozapine has been known to cause an antagonistic myoclonic jerk that leads to knee buckling. Here, we present the case of a 29-year-old female who is being treated for schizoaffective disorder, bipolar, manic type, who reported two instances of knee buckling associated with falls while taking clozapine.
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Affiliation(s)
| | - Ernesto Navarro Garcia
- Nanotechnology, University of Central Florida, Orlando, USA
- Physiology and Neuroscience, St George's University, St. George's, GRD
| | - Hiba Al-Rubaye
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
| | - Carlos Julian
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
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3
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Kappel DB, Rees E, Fenner E, King A, Jansen J, Helthuis M, Owen MJ, O'Donovan MC, Walters JTR, Pardiñas AF. Rare variants in pharmacogenes influence clozapine metabolism in individuals with schizophrenia. Eur Neuropsychopharmacol 2024; 80:47-54. [PMID: 38310750 DOI: 10.1016/j.euroneuro.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 02/06/2024]
Abstract
Clozapine is the only licensed medication for treatment-resistant schizophrenia (TRS). Few predictors for variation in response to clozapine have been identified, but clozapine metabolism is known to influence therapeutic response and adverse side effects. Here, we expand on genome-wide studies of clozapine metabolism, previously focused on common genetic variation, by analysing whole-exome sequencing data from 2062 individuals with schizophrenia taking clozapine in the UK. We investigated whether rare genomic variation in genes and gene sets involved in the clozapine metabolism pathway influences plasma concentrations of clozapine metabolites, assessed through the longitudinal analysis of 6585 pharmacokinetic assays. We observed a statistically significant association between the burden of rare damaging coding variants (MAF ≤ 1 %) in gene sets broadly related to drug pharmacokinetics and lower clozapine (β = -0.054, SE = 0.019, P-value = 0.005) concentrations in plasma. We estimate that the effects in clozapine plasma concentrations of a single damaging allele in this gene set are akin to reducing the clozapine dose by about 35 mg/day. The gene-based analysis identified rare variants in CYP1A2, which encodes the enzyme responsible for converting clozapine to norclozapine, as having the strongest effects of any gene on clozapine metabolism (β = 0.324, SE = 0.124, P = 0.009). Our findings support the hypothesis that rare genetic variants in known drug-metabolising enzymes and transporters can markedly influence clozapine plasma concentrations; these results suggest that pharmacogenomic efforts trying to predict clozapine metabolism and personalise drug therapy could benefit from the inclusion of rare damaging variants in pharmacogenes beyond those already identified and catalogued as PGx star alleles.
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Affiliation(s)
- Djenifer B Kappel
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Elliott Rees
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Eilidh Fenner
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Adrian King
- Magna Laboratories Ltd., Ross-on-Wye, United Kingdom
| | - John Jansen
- Leyden Delta B.V., Nijmegen, The Netherlands
| | | | - Michael J Owen
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Michael C O'Donovan
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James T R Walters
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Antonio F Pardiñas
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom.
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Mishra A, Maiti R, Mishra BR, Srinivasan A. Efficacy of pharmacological agents for the management of treatment-resistant schizophrenia: a network meta-analysis. Expert Rev Clin Pharmacol 2024; 17:293-302. [PMID: 38269529 DOI: 10.1080/17512433.2024.2310715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE The present network meta-analysis (NMA) was conducted to compare and generate evidence for the most efficacious treatment among available pharmacological interventions for treatment-resistant schizophrenia (TRS). METHODS Reviewers extracted data from 47 studies screened from PubMed/MEDLINE, Embase, Cochrane databases and clinical trial registries fulfilling the eligibility criteria. Random effects Bayesian NMA was done with non-informative priors. Network geometry was visualized, and node splitting was done for the closed triangles. Standardized mean difference and 95% credible interval(95%CrI) were reported for the reduction in symptom severity scores. The probability of each intervention for each rank was plotted. Meta-regression was done for the duration of the therapy. RESULTS Augmentation of antipsychotics with escitalopram (SMD: -1.7[95%CrI: -2.8, -0.70]), glycine (SMD: -1.2 [95%CrI: -2.2, -0.28]) and Yokukansan (SMD: -1.3 [95%CrI: -2.4, -0.24]) shows a statistically significant reduction in symptom severity when compared to clozapine. As per surface under cumulative ranking curve analysis, escitalopram in combination with antipsychotics appeared to be the best intervention with moderate certainty of evidence. There was no significant effect of the duration of therapy on the treatment effects. CONCLUSION Escitalopram augmentation of antipsychotics appears to be the most efficacious treatment with moderate certainty of evidence among the available pharmacological interventions. PROSPERO REGISTRATION CRD42022380292.
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Affiliation(s)
- Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Siriwardena D, Gauci CM, Mohtashami A, Badiani S, Kabir S. Clozapine-Induced Refractory Colonic Pseudo-Obstruction. Cureus 2024; 16:e53377. [PMID: 38435172 PMCID: PMC10907970 DOI: 10.7759/cureus.53377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
The management of treatment-resistant schizophrenia (TRS) is challenging as the medications involved, often atypical antipsychotics, have a host of associated adverse effects. While complications such as agranulocytosis are well established and necessitate close hematological monitoring, the gastrointestinal effects of particular atypical antipsychotics, such as clozapine, are recognized to a lesser extent. The following case of TRS leading to chronic treatment-resistant pseudo-obstruction, eventually requiring total colectomy, highlights the considerable sequelae of clozapine on the gastrointestinal tract. Beyond the effects of severe constipation, the possible implications of ischemic colitis, stercoral perforation, and intraabdominal sepsis warrant a degree of caution when prescribing such medication. This study sheds light on the importance of monitoring bowel motility when administering antipsychotics, particularly clozapine, to avoid these deleterious consequences.
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Affiliation(s)
| | - Chahaya M Gauci
- Colorectal Surgery, Royal North Shore Hospital, Sydney, AUS
- Medicine and Health, University of Sydney, Sydney, AUS
- Medicine and Surgery, University of New South Wales, Sydney, AUS
- Surgery, Hepatobiliary and Surgical Oncology Unit, St George Hospital, Kogarah, AUS
| | - Ali Mohtashami
- Colorectal Surgery, Royal North Shore Hospital, Sydney, AUS
| | | | - Shahrir Kabir
- Colorectal Surgery, Royal North Shore Hospital, Sydney, AUS
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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7
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Reeves S, Bertrand J, Obee SJ, Hunter S, Howard R, Flanagan RJ. A population pharmacokinetic model to guide clozapine dose selection, based on age, sex, ethnicity, body weight and smoking status. Br J Clin Pharmacol 2024; 90:135-145. [PMID: 36793249 DOI: 10.1111/bcp.15691] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
AIMS Guidance on clozapine dosing in treatment-resistant schizophrenia is based largely on data from White young adult males. This study aimed to investigate the pharmacokinetic profiles of clozapine and N-desmethylclozapine (norclozapine) across the age range, accounting for sex, ethnicity, smoking status and body weight. METHODS A population pharmacokinetic model, implemented in Monolix, that linked plasma clozapine and norclozapine via a metabolic rate constant, was used to analyse data from a clozapine therapeutic drug monitoring service, 1993-2017. RESULTS There were 17 787 measurements from 5960 patients (4315 male) aged 18-86 years. The estimated clozapine plasma clearance was reduced from 20.2 to 12.0 L h-1 between 20 and 80 years. Model-based dose predictions to attain a predose plasma clozapine concentration of 0.35 mg L-1 was 275 (90% prediction interval 125, 625) mg day-1 in nonsmoking, White males weighing 70 kg and aged 40 years. The corresponding predicted dose was increased by 30% in smokers, decreased by 18% in females, and was 10% higher and 14% lower in otherwise analogous Afro-Caribbean and Asian patients, respectively. Overall, the predicted dose decreased by 56% between 20 and 80 years. CONCLUSION The large sample size and wide age range of the patients studied allowed precise estimation of dose requirements to attain predose clozapine concentration of 0.35 mg L-1 . The analysis was, however, limited by the absence of data on clinical outcome and future studies are required to determine optimal predose concentrations specifically in those aged over 65 years.
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Affiliation(s)
- Suzanne Reeves
- Division of Psychiatry, University College London, London, UK
| | - Julie Bertrand
- Institute of Genetics, University College London, London, UK
- UMR 1137 Infection, Antimicrobials, Modelling, Evolution (IAME) French Institute for Medical Research (INSERM), University of Paris, Paris, France
| | - Stephen John Obee
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Samora Hunter
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Robert James Flanagan
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
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8
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Stogios N, Humber B, Agarwal SM, Hahn M. Antipsychotic-Induced Weight Gain in Severe Mental Illness: Risk Factors and Special Considerations. Curr Psychiatry Rep 2023; 25:707-721. [PMID: 37755655 DOI: 10.1007/s11920-023-01458-0] [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] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW Weight gain is a disconcerting issue experienced by patients treated with antipsychotics (APs). This review summarizes current knowledge on the prevalence, etiology, and risk factors for antipsychotic-induced weight gain (AIWG), and evidence for interventions, including special considerations. RECENT FINDINGS Predisposing risk factors for AIWG include lack of prior AP exposure, sex, and age. AP dose and duration of exposure are additional treatment-related factors that may contribute to this issue. Among current approaches to target AIWG, metformin has the most evidence to support its use, and this is increasingly reflected in clinical guidelines. While lifestyle approaches are recommended, cost-effectiveness and scalability represent limitations. More research is needed to identify newer treatment options and inform clinical recommendations for AIWG. Concerns around scope of practice in psychiatry to address AIWG and related comorbidities will require enhanced training opportunities and interdisciplinary collaborations, as well as updated position statements/practice guidelines emphasizing prevention.
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Affiliation(s)
- Nicolette Stogios
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen Street West, Toronto, ON, M6J 1H3, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Bailey Humber
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen Street West, Toronto, ON, M6J 1H3, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Sri Mahavir Agarwal
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen Street West, Toronto, ON, M6J 1H3, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Banting and Best Diabetes Centre (BBDC), University of Toronto, Toronto, Canada
| | - Margaret Hahn
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen Street West, Toronto, ON, M6J 1H3, Canada.
- Institute of Medical Science, University of Toronto, Toronto, Canada.
- Department of Psychiatry, University of Toronto, Toronto, Canada.
- Banting and Best Diabetes Centre (BBDC), University of Toronto, Toronto, Canada.
- Department of Pharmacology, University of Toronto, Toronto, Canada.
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De Pieri M, Poglia G, Bartolomei J. Case report: 10 years follow-up of psychosis due to Fahr's disease complicated by a left temporal stroke. Front Psychiatry 2023; 14:1268982. [PMID: 38016060 PMCID: PMC10644033 DOI: 10.3389/fpsyt.2023.1268982] [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: 07/28/2023] [Accepted: 10/03/2023] [Indexed: 11/30/2023] Open
Abstract
Fahr's disease (FD) is a rare disorder, characterized by basal ganglia calcification and presenting with movement disorders, speech impairment, cognitive deficits, and neuropsychiatric symptoms. Psychotic disorders related to FD are barely described in the literature, and knowledge is missing concerning pathophysiology, course, and management. Here, we report on the long-term follow-up of a patient who had three acute episodes of FD-psychosis characterized by bizarre delusions and behavioral disorganization, without hallucinations. Genetic and metabolic causes of FD were ruled out. In all three episodes, olanzapine monotherapy rapidly and completely resolved psychosis, without inducing metabolic syndrome and extrapyramidal symptoms. In addition to the acute decompensations, the patient presented a tame, introverted, industrious, and perfectionistic personality, which we could interpret as the "parkinsonian personality" described for many other basal ganglia disorders. Moreover, bizarre appearance, reduced affectivity, abulia, concrete speech, and stiff motricity in the context of a mild asymmetric extrapyramidal syndrome characterized the mental status. The cognitive profile was initially marked by executive difficulties and partial agnosia, with an IQ of 86. In the course of 10 years, the patient suffered from an ischemic stroke in the left superior temporal gyrus, which provoked a decline in memory and executive functions, without any impact on the psychiatric picture. Antiphospholipid antibody syndrome emerged as the underlying cause; thus, for the first time in the literature, an overlap of FD and antiphospholipid antibody syndrome is described here. This case report stresses once more the need for better integration of psychiatry and neurology and for the investigation of secondary causes of late-onset psychosis.
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Affiliation(s)
- Marco De Pieri
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
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Smith ECC, Au E, Pereira S, Sharma E, Venkatasubramanian G, Remington G, Agarwal SM, Hahn M. Clinical improvement in schizophrenia during antipsychotic treatment in relation to changes in glucose parameters: A systematic review. Psychiatry Res 2023; 328:115472. [PMID: 37722239 DOI: 10.1016/j.psychres.2023.115472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/20/2023]
Abstract
Antipsychotics (APs) are the cornerstone of treatment for schizophrenia (SCZ) spectrum disorders. Previous research suggests that there may be a positive association between AP-induced weight gain and/or dyslipidemia and improvement in psychiatric symptoms, often referred to as a "metabolic threshold". To determine whether a similar relationship exists for glucose parameters, we conducted a systematic search in six databases from inception to June 2022 for all longitudinal studies that directly examined the relationship between changes in glucose-related outcomes and changes in psychopathology among patients with SCZ treated with APs. We identified 10 relevant studies and one additional study that considered cognition. In most cases, we found that increased levels of fasting glucose and insulin following treatment were associated with clinical improvement. These findings contribute to existing literature that could suggest a common mechanism between AP action and metabolic side effects and support a need for additional work aimed at exploring the validity of a glucose-psychopathology relation in SCZ.
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Affiliation(s)
- Emily Chen Chen Smith
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Institute of Medical Sciences, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Emily Au
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Department of Pharmacology, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 4207, Toronto, ON, Canada
| | - Sandra Pereira
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Department of Physiology, University of Toronto, 1 King's College Circle, Medical Sciences Building, 3rd floor, Toronto, ON M5S 1A8, Canada
| | - Eesha Sharma
- National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560029, Karnataka, India
| | | | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Institute of Medical Sciences, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON M5T 1R8, Canada
| | - Sri Mahavir Agarwal
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Institute of Medical Sciences, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON M5T 1R8, Canada; Banting and Best Diabetes Centre, University of Toronto, 200 Elizabeth Street, Eaton Building, 12th Floor, Room 12E248, Toronto, ON M5G 2C4, Canada
| | - Margaret Hahn
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), 1051 Queen St. W, Toronto, ON M6J 1H3, Canada; Institute of Medical Sciences, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON M5T 1R8, Canada; Banting and Best Diabetes Centre, University of Toronto, 200 Elizabeth Street, Eaton Building, 12th Floor, Room 12E248, Toronto, ON M5G 2C4, Canada.
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11
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Grover S, Mishra E, Chakrabarti S. Dropout rates and reasons for dropout among patients receiving clozapine. Indian J Psychiatry 2023; 65:680-686. [PMID: 37485413 PMCID: PMC10358823 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_819_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/05/2023] [Accepted: 05/06/2023] [Indexed: 07/25/2023] Open
Abstract
Background and Aim The present study aimed to assess the treatment dropout rates, reasons for treatment dropout, and clozapine discontinuation rate among patients attending a tertiary care center in North India. Materials and Methods Clozapine data bank was used to identify patients on clozapine, and their treatment records were reviewed for the period Jan 2020-March 2020. Patients who did not follow-up at least once in the last 6 months were considered to have dropped out and were contacted telephonically to understand the reasons for dropout. Treatment records of those following up regularly were reviewed to check if clozapine was discontinued and if so, the reason for the same was evaluated. Results Out of 671 patients on clozapine, 495 (73.8%) were still on regular follow-up and the remaining 176 (26.2%) had dropped out of treatment. Out of the 176 patients who had dropped out of treatment, 84 could be contacted. Common reasons for dropout were long distance from the hospital (n = 27), long waiting time for consultation (n = 8), no benefit with treatment (n = 17), side effects with medication (n = 10), moving away to another place (n = 6), refusal by the patient to follow-up (n = 7), patient improved and so did not feel the need to continue treatment (n = 7), and other reasons (n = 37). Conclusion About one-fourth of patients who had started treatment with clozapine dropped out from the treatment. The most common reasons for dropout from treatment included long distance from the hospital and no benefit from treatment.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Eepsita Mishra
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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12
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Eo J, Kang J, Youn T, Park HJ. Neuropharmacological computational analysis of longitudinal electroencephalograms in clozapine-treated patients with schizophrenia using hierarchical dynamic causal modeling. Neuroimage 2023; 275:120161. [PMID: 37172662 DOI: 10.1016/j.neuroimage.2023.120161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023] Open
Abstract
The hierarchical characteristics of the brain are prominent in the pharmacological treatment of psychiatric diseases, primarily targeting cellular receptors that extend upward to intrinsic connectivity within a region, interregional connectivity, and, consequently, clinical observations such as an electroencephalogram (EEG). To understand the long-term effects of neuropharmacological intervention on neurobiological properties at different hierarchical levels, we explored long-term changes in neurobiological parameters of an N-methyl-D-aspartate canonical microcircuit model (CMM-NMDA) in the default mode network (DMN) and auditory hallucination network (AHN) using dynamic causal modeling of longitudinal EEG in clozapine-treated patients with schizophrenia. The neurobiological properties of the CMM-NMDA model associated with symptom improvement in schizophrenia were found across hierarchical levels, from a reduced membrane capacity of the deep pyramidal cell and intrinsic connectivity with the inhibitory population in DMN and intrinsic and extrinsic connectivity in AHN. The medication duration mainly affects the intrinsic connectivity and NMDA time constant in DMN. Virtual perturbation analysis specified the contribution of each parameter to the cross-spectral density (CSD) of the EEG, particularly intrinsic connectivity and membrane capacitances for CSD frequency shifts and progression. It further reveals that excitatory and inhibitory connectivity complements frequency-specific CSD changes, notably the alpha frequency band in DMN. Positive and negative synergistic interactions exist between neurobiological properties primarily within the same region in patients treated with clozapine. The current study shows how computational neuropharmacology helps explore the multiscale link between neurobiological properties and clinical observations and understand the long-term mechanism of neuropharmacological intervention reflected in clinical EEG.
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Affiliation(s)
- Jinseok Eo
- Graduate School of Medical Science, Brain Korea 21 Project, Department of Nuclear Medicine, Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea; Center for Systems and Translational Brain Science, Institute of Human Complexity and Systems Science, Yonsei University, Seoul, Republic of Korea
| | - Jiyoung Kang
- Department of Scientific Computing, Pukyong National University, Busan, Republic of Korea; Center for Systems and Translational Brain Science, Institute of Human Complexity and Systems Science, Yonsei University, Seoul, Republic of Korea
| | - Tak Youn
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea; Institute of Buddhism and Medicine, Dongguk University, Seoul, Republic of Korea
| | - Hae-Jeong Park
- Graduate School of Medical Science, Brain Korea 21 Project, Department of Nuclear Medicine, Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea; Center for Systems and Translational Brain Science, Institute of Human Complexity and Systems Science, Yonsei University, Seoul, Republic of Korea; Department of Cognitive Science, Yonsei University, Seoul, Republic of Korea.
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13
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Pardiñas AF, Kappel DB, Roberts M, Tipple F, Shitomi-Jones LM, King A, Jansen J, Helthuis M, Owen MJ, O'Donovan MC, Walters JTR. Pharmacokinetics and pharmacogenomics of clozapine in an ancestrally diverse sample: a longitudinal analysis and genome-wide association study using UK clinical monitoring data. Lancet Psychiatry 2023; 10:209-219. [PMID: 36804072 PMCID: PMC10824469 DOI: 10.1016/s2215-0366(23)00002-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND The antipsychotic, clozapine, is the only licensed drug against the treatment-resistant symptoms that affect 20-30% of people with schizophrenia. Clozapine is markedly underprescribed, partly because of concerns about its narrow therapeutic range and adverse drug reaction profile. Both concerns are linked to drug metabolism, which varies across populations globally and is partly genetically determined. Our study aimed to use a cross-ancestry genome-wide association study (GWAS) design to investigate variations in clozapine metabolism within and between genetically inferred ancestral backgrounds, to discover genomic associations to clozapine plasma concentrations, and to assess the effects of pharmacogenomic predictors across different ancestries. METHODS In this GWAS, we analysed data from the UK Zaponex Treatment Access System clozapine monitoring service as part of the CLOZUK study. We included all available individuals with clozapine pharmacokinetic assays requested by their clinicians. We excluded people younger than 18 years, or whose records contained clerical errors, or with blood drawn 6-24 h after dose, a clozapine or norclozapine concentration less than 50 ng/mL, a clozapine concentration of more than 2000 ng/mL, a clozapine-to-norclozapine ratio outside of the 0·5-3·0 interval, or a clozapine dose of more than 900 mg/day. Using genomic information, we identified five biogeographical ancestries: European, sub-Saharan African, north African, southwest Asian, and east Asian. We did pharmacokinetic modelling, a GWAS, and a polygenic risk score association analysis using longitudinal regression analysis with three primary outcome variables: two metabolite plasma concentrations (clozapine and norclozapine) and the clozapine-to-norclozapine ratio. FINDINGS 19 096 pharmacokinetic assays were available for 4760 individuals in the CLOZUK study. After data quality control, 4495 individuals (3268 [72·7%] male and 1227 [27·3%] female; mean age 42·19 years [range 18-85]) linked to 16 068 assays were included in this study. We found a faster average clozapine metabolism in people of sub-Saharan African ancestry than in those of European ancestry. By contrast, individuals with east Asian or southwest Asian ancestry were more likely to be slow clozapine metabolisers than those with European ancestry. Eight pharmacogenomic loci were identified in the GWAS, seven with significant effects in non-European groups. Polygenic scores generated from these loci were associated with clozapine outcome variables in the whole sample and within individual ancestries; the maximum variance explained was 7·26% for the metabolic ratio. INTERPRETATION Longitudinal cross-ancestry GWAS can discover pharmacogenomic markers of clozapine metabolism that, individually or as polygenic scores, have consistent effects across ancestries. Our findings suggest that ancestral differences in clozapine metabolism could be considered for optimising clozapine prescription protocols for diverse populations. FUNDING UK Academy of Medical Sciences, UK Medical Research Council, and European Commission.
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Affiliation(s)
- Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK.
| | - Djenifer B Kappel
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Milly Roberts
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Francesca Tipple
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Lisa M Shitomi-Jones
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael C O'Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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14
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Miller BJ, McEvoy JP, McCall WV. Meta-analysis of clozapine and insomnia in schizophrenia. Schizophr Res 2023; 252:208-215. [PMID: 36669344 DOI: 10.1016/j.schres.2023.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/21/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Insomnia commonly occurs in schizophrenia, and insomnia is associated with suicide risk. Clozapine has anti-suicidal properties and beneficial effects on sleep. We performed a meta-analysis of insomnia in randomized controlled trials (RCTs) of patients with schizophrenia treated with clozapine. We hypothesized that compared to clozapine there is an increased odds of insomnia in patients treated with other antipsychotics. METHODS We systematically searched PubMed, PsycINFO, and Web of Science databases. We included RCTs, in English, with data on insomnia in patients with schizophrenia treated with clozapine versus other antipsychotics. Data were pooled using a random effects model. RESULTS Eight RCTs (1952 patients: 922 on clozapine and 1030 on other antipsychotics) met inclusion criteria. Patients treated with other antipsychotics versus clozapine had a significant increased odds of insomnia (22.3 % versus 12.4 %, OR = 2.20, 95 % CI = 1.64-2.94, p < 0.01). Olanzapine, quetiapine, risperidone, and ziprasidone were each associated with significant increased odds of insomnia compared to clozapine. In meta-regression analyses, clozapine dose, publication year, sex, trial duration, and study quality score were unrelated to the association; however, there was a significant association with age. The observed ORs for insomnia from RCTs were almost perfectly correlated with reported ORs from pharmacovigilance data. CONCLUSION Clozapine is associated with significantly less insomnia compared to other antipsychotics. Findings provide additional evidence for improvement in sleep as a potential pathway underlying clozapine's anti-suicidal properties. A greater mechanistic understanding of this association is needed.
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Affiliation(s)
- Brian J Miller
- Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA, United States.
| | - Joseph P McEvoy
- Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA, United States
| | - William V McCall
- Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA, United States
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15
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Gannon L, Reynolds J, Mahon M, Gaughran F, Lally J. High-dose olanzapine in treatment-resistant schizophrenia: a systematic review. Ther Adv Psychopharmacol 2023; 13:20451253231168788. [PMID: 37187727 PMCID: PMC10176543 DOI: 10.1177/20451253231168788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/23/2023] [Indexed: 05/17/2023] Open
Abstract
Background Treatment-resistant schizophrenia (TRS) affects approximately 30% of people with schizophrenia. Clozapine is the gold standard treatment for TRS but is not always suitable, with a proportion of individuals intolerant of side effects or unable to engage in necessary blood monitoring. Given the profound impact TRS can have on those affected, alternative pharmacological approaches to care are needed. Objectives To review the literature on the efficacy and tolerability of high-dose olanzapine (>20 mg daily) in adults with TRS. Design This is a systematic review. Data Sources and Methods We searched for eligible trials published prior to April 2022 in PubMed/MEDLINE, Scopus and Google Scholar. Ten studies met the inclusion criteria [five randomised controlled trials (RCTs), one randomised crossover trial and four open label studies]. Data were extracted for predefined primary outcomes (efficacy, tolerability). Results Compared with standard treatment, high-dose olanzapine was non-inferior in four RCTs, three of which used clozapine as the comparator. Clozapine was superior to high-dose olanzapine in a double-blind crossover trial. Open-label studies demonstrated tentative evidence in support of high-dose olanzapine use. It was better tolerated than clozapine and chlorpromazine in two respective RCTs, and was generally well tolerated in open-label studies. Conclusion This evidence suggests high-dose olanzapine is superior for TRS when compared with other commonly used first- and second-generation antipsychotics, including haloperidol and risperidone. In comparison with clozapine, the data are encouraging for the use of high-dose olanzapine where clozapine use is problematic, but larger, better designed trials are needed to assess the comparative efficacy of both treatments. There is insufficient evidence to consider high-dose olanzapine equivalent to clozapine when clozapine is not contraindicated. Overall, high-dose olanzapine was well tolerated, with no serious side effects. Registration This systematic review was preregistered with PROSPERO [CRD42022312817].
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Affiliation(s)
- Louisa Gannon
- Department of Psychiatry, University College
Dublin, Dublin, Ireland
- Department of Psychiatry, St. Vincent’s
University Hospital, Dublin, Ireland
| | - John Reynolds
- Department of Psychiatry, Mayo University
Hospital, Castlebar, Ireland
| | - Martin Mahon
- Department of Psychiatry, Connolly Hospital,
Dublin, Ireland
| | - Fiona Gaughran
- National Psychosis Service, South London and
Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of
Psychiatry Psychology and Neuroscience, Kings College London, London,
UK
- National Institute for Health Research (NIHR)
Mental Health Biomedical Research Centre at South London and Maudsley NHS
Foundation Trust and King’s College London, UK
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16
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Shi H, Xu J, Lang X, Wu HE, Xiu MH, Zhang XY. Comparison of Efficacy and Safety Between Low-Dose Ziprasidone in Combination With Sertraline and Ziprasidone Monotherapy for Treatment-Resistant Patients With Acute Exacerbation Schizophrenia: A Randomized Controlled Trial. Front Pharmacol 2022; 13:863588. [PMID: 35559243 PMCID: PMC9086512 DOI: 10.3389/fphar.2022.863588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Treatment-resistant schizophrenia (TRS) is a prevalent clinical problem with heterogeneous presentations. However, the clinical trial designs for new treatments are still lacking. This study aimed to assess the efficacy of ziprasidone plus sertraline in TRS patients as compared to ziprasidone monotherapy. We conducted a 24 weeks, randomized, controlled, double-blinded clinical research trial. 62 treatment-resistant patients with acute exacerbation SZ were randomly allocated to receive a usual dose of ziprasidone (120-160 mg/d) monotherapy (Control group) and 53 TRS inpatients were to receive a low dose of ziprasidone (60-80 mg/d) in combination with sertraline (ZS group). Treatment outcomes were measured by the Positive and Negative Syndrome Scale (PANSS), the Hamilton Depression Rating Scale (HAMD), CGI-Severity (CGI-S) and Personal and Social Performance Scale (PSP) at baseline, week 4, 8, 12, and 24. Relative to control group, the patients in ZS group showed greater reductions in the following: PANSS positive symptom, negative symptom, total score, and HAMD total score. Additionally, the patients in ZS group had a greater increase in PSP total score. Notably, the reduction in HAMD was positively correlated with the reduction in PANSS total score. The reduction in CGI-S was a predictor for the improvement of psychosocial functioning in patients. Furthermore, the ZS group had a lower rate of side effects compared to the control group. Our findings suggest that a low dose of ziprasidone in combination with sertraline is an effective therapy for the clinical symptoms as compared to a usual dose of ziprasidone in the treatment-resistant patients with acute exacerbation SZ. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04076371.
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Affiliation(s)
- Hui Shi
- Department of Psychiatry, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Xu
- Qingdao Mental Health Center, Qingdao Medical University, Qingdao, China
| | - Xiaoe Lang
- Department of Psychiatry, Shanxii Medical University, Taiyuan, China
| | - Hanjing Emily Wu
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mei Hong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Xiang Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China.,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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17
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Holden J, Begum M. Successful rechallenge after clozapine-associated myocarditis. BMJ Case Rep 2022; 15:e248909. [PMID: 35550318 PMCID: PMC9109022 DOI: 10.1136/bcr-2022-248909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/03/2022] Open
Abstract
Clozapine is a highly effective medication used in management of treatment-resistant schizophrenia. Clozapine-associated myocarditis (CAM) is a rare but increasingly recognised complication of clozapine titration. Following an episode of CAM, clinicians can face a challenging dilemma of balancing the risks of recurrent myocarditis against the harms of ongoing psychosis. We describe the case of a woman in her 60s who developed acute myocarditis during clozapine titration and was then cautiously rechallenged with a successful outcome.
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Affiliation(s)
- John Holden
- Psychiatry, NHS Ayrshire and Arran Woodland View, Irvine, UK
| | - Milia Begum
- Psychiatry, NHS Ayrshire and Arran Woodland View, Irvine, UK
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18
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Determining nonesterified and total docosahexaenoic acid and eicosapenaenoic acid concentrations by LC-MS/MS in the plasma of patients with schizophrenia. Bioanalysis 2022; 14:467-477. [PMID: 35469438 DOI: 10.4155/bio-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Nonesterified, total docosahexaenoic acid (DHA) and eicosapenaenoic acid (EPA) plasma levels were evaluated in patients with schizophrenia on different medications compared with healthy individuals using validated LC-MS/MS methods. Methods: Samples for nonesterified DHA and EPA assay were extracted in n-hexane-dichloromethane-isopropyl alcohol (2:1:0.1, V/V/V) and hydrolyzed at 90°C for 2 h before total DHA and EPA determination. Methods were validated in surrogate matrix and plasma. Results: These methods generated similar recovery for plasma (>89%) and surrogate matrix (>87%) and negligible matrix effects. Linearity, lower limit of quantification, accuracy, precision and stability were also validated. Conclusions: This study successfully determined DHA and EPA plasma levels in patients with schizophrenia and healthy individuals using validated LC-MS/MS methods. Therefore, nonesterified DHA and total EPA levels could be used as schizophrenia biomarkers.
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19
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Hassab Errasoul A, Alarabi MA. Factors predicting serum clozapine levels in Middle Eastern patients: an observational study. BMC Psychiatry 2022; 22:269. [PMID: 35428222 PMCID: PMC9011948 DOI: 10.1186/s12888-022-03910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Despite its superiority over other drugs for psychosis, clozapine remains underused and is associated with many clinical challenges, including difficulties in predicting therapeutic serum levels (350-600 ng/mL). We found no large or recent study that investigated the determinants of serum clozapine levels in Middle Eastern patients. Therefore, we investigated the association between clozapine dose and serum level, and the clinical predictors of the clozapine serum level, in Middle Eastern patients. METHODS This cross-sectional study included 94 patients of Middle Eastern ethnicity who attended the Clozapine Clinic in King Saud University Medical City in Riyadh, Saudi Arabia. We used a single measure of the serum clozapine level, which was collected 12 h after the last oral dose of clozapine under steady-state conditions. RESULTS The average clozapine dose and serum level were 400 mg/daily and 705 ng/mL, respectively. The majority of patients (59.8%) had serum levels higher than 600 ng/mL. Clozapine dose and serum level were positively correlated (rs [94] = 0.32, p = 0.002). We generated a predictive model of the serum clozapine level, which revealed that the daily dose, smoking status, use of fluvoxamine or lamotrigine, and body mass index (BMI) predicted 43.6% of the variance in the serum level (p < 0.001). Using this model, we calculated that patients with a BMI of 25 kg/m2 would require a clozapine dose between 50 to 275 mg/daily if they were non-smokers, and a dose of 200 to 450 mg/daily if they were smokers, in order to reach a serum clozapine level between 350 to 600 ng/mL. Patients with higher BMI and those receiving fluvoxamine would require lower doses. CONCLUSIONS This was a naturalistic study of the clozapine dose-level relationship and the clinical predictors of the serum clozapine level in a sample of Middle Eastern patients. The ratios of clozapine level to dose in our patients more closely resembled those reported in Asian samples than in European samples. These findings do not reduce the value of individualised therapeutic drug monitoring, but may assist clinicians when prescribing clozapine to Middle Eastern patients. Further psychopharmacological studies are needed on this demographic population.
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Affiliation(s)
- Ahmed Hassab Errasoul
- grid.56302.320000 0004 1773 5396Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472 Kingdom of Saudi Arabia
| | - Mohammed A. Alarabi
- grid.56302.320000 0004 1773 5396Department of Psychiatry, College of Medicine, King Saud University, PO Box 7805, Riyadh, 11472 Kingdom of Saudi Arabia
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20
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Handley SA, Every-Palmer S, Ismail A, Flanagan RJ. Clozapine-induced gastrointestinal hypomotility: presenting features and outcomes, UK pharmacovigilance reports, 1992-2017. Br J Psychiatry 2022; 220:1-9. [PMID: 35164895 DOI: 10.1192/bjp.2022.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clozapine-induced gastrointestinal hypomotility (CIGH) affects some 75% of patients treated with clozapine. AIMS To document the incidence of potentially harmful CIGH in the UK. METHOD We studied spontaneous UK pharmacovigilance reports recorded as clozapine-related gastrointestinal adverse drug reactions, 1992-2017. RESULTS There were 527 patients reported with potentially harmful CIGH; 33% (n = 172) died. Deaths averaged 1 per year 1992-1999, 5 per year 2000-2009 and 15 per year 2010-2017. Those who died were older (median 52 years v. 49 years) and had been prescribed clozapine for longer than those who recovered (median 11.3 years v. 4.8 years), but there was no difference in prescribed dose. Within the first 4 years of clozapine treatment, there were 169 reports of CIGH, of which 3% (n = 5) were fatal. At 10-14 years there were 63 reports of CIGH, of which 25% (n = 16) were fatal. Among the deaths, males were younger (median 51, range 22-89 v. median 57, range 24-89 years) with higher clozapine doses (median 450, range 100-900 v. median 300, range 12.5-800 mg/d) than females. In non-fatal CIGH, surgery was the most frequent outcome (n = 92). The procedures included appendectomy, ileostomy, total/partial colectomy, colostomy/stoma and proctosigmoidectomy. Clozapine dosage was reduced in 6 patients, stopped and restarted in 23, 'continued' in 6 and discontinued permanently in at least 76 patients. CONCLUSIONS The risk of serious morbidity/mortality from CIGH is substantial. The need to actively monitor bowel function and give laxatives to patients treated with clozapine is clear.
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Affiliation(s)
- S A Handley
- Department of Pathology, Royal Hobart Hospital, Australia
| | - S Every-Palmer
- Department of Psychological Medicine, University of Otago, New Zealand
| | - A Ismail
- Manor Drive Medical Centre and West Barnes Surgery, UK and Medicines and Healthcare Products Regulatory Agency, UK
| | - R J Flanagan
- Precision Medicine, Networked Services, King's College Hospital, UK
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21
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Miller BJ, McCall WV. Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers. J Clin Sleep Med 2022; 18:517-522. [PMID: 34543183 PMCID: PMC8804988 DOI: 10.5664/jcsm.9646] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES Insomnia and suicide ideation/behavior/death (SIB) are common in psychiatric disorders. There is evidence that clozapine and lithium have antisuicidal properties and beneficial effects on sleep. We investigated the reported odds of spontaneously reported psychiatric adverse drug reactions of insomnia and SIB in adults for second-generation antipsychotics (SGAs) and mood stabilizers compared to clozapine and lithium, respectively. METHODS We searched the U.S. Food & Drug Administration Adverse Event Reporting System from inception through February 2021 for which an SGA or mood stabilizer was the suspected agent of a psychiatric adverse drug reaction. RESULTS We investigated 10 SGAs and 5 mood stabilizers. Compared to clozapine, other SGAs were associated with a significantly increased reported odds of insomnia (reported odds ratio [rOR] = 2.41-9.70) and SIB (rOR = 1.18-2.72). Compared to lithium, there was a significantly increased reported odds of SIB (rOR = 1.17-1.70) for other mood stabilizers and odds of insomnia (rOR = 1.66) for lamotrigine. The insomnia and SIB rORs for SGAs and mood stabilizers were positively correlated. CONCLUSIONS Our results are consistent with evidence for antisuicidal properties of clozapine and lithium. Findings also raise the possibility of beneficial effects on sleep as one potential pathway underlying the antisuicidal properties for these agents. Future studies are needed to identify underlying biological mechanisms that contribute to these associations. CITATION Miller BJ, McCall WV. Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers. J Clin Sleep Med. 2022;18(2):517-522.
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Affiliation(s)
| | - William V. McCall
- Address correspondence to: William V. McCall, MD, MS, Department of Psychiatry and Health Behavior, Augusta University, 997 Saint Sebastian Way, Augusta, GA 30912; Tel: (706) 721-6719; Fax: (706) 721-1793;
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22
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Influence of haloperidol and clozapine on the cognitive performance in patients with psychotic disorders: possible attributes. CNS Spectr 2022; 28:281. [PMID: 35078548 DOI: 10.1017/s1092852922000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Bu K, Patel D, Morris R, Han W, Umeukeje G, Zhu T, Cheng F. Dysphagia Risk in Patients Prescribed Rivastigmine: A Systematic Analysis of FDA Adverse Event Reporting System. J Alzheimers Dis 2022; 89:721-731. [PMID: 35964196 DOI: 10.3233/jad-220583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dysphagia has been reported as an adverse event for patients receiving rivastigmine for Alzheimer's disease (AD) treatment. OBJECTIVE The purpose of this study was to determine the association between dysphagia and the usage of rivastigmine by using the pharmacovigilance data from the FDA Adverse Event Reporting System (FAERS). METHODS The risk of dysphagia in patients who took rivastigmine was compared with those of patients who took other medications. In addition, this study sought to determine if the dysphagia risk was influenced by sex, age, dosage, and medication routes of administration. RESULTS When compared to patients prescribed donepezil, galantamine, or memantine, individuals prescribed rivastigmine were almost twice as likely to report dysphagia as an adverse event. The dysphagia risk in individuals prescribed rivastigmine is comparable to individuals prescribed penicillamine but significantly higher than clozapine, drugs of which have been previously shown to be associated with elevated dysphagia likelihood. Individuals older than 80 were 122% more likely to report having dysphagia after being prescribed rivastigmine than patients that were 50-70 years of age. Oral administration of rivastigmine was associated with approximately 2 times greater likelihood of reporting dysphagia relative to users of the transdermal patch. In addition, dysphagia showed higher association with pneumonia than other commonly reported adverse events. CONCLUSION Patients prescribed rivastigmine were at greater risk of reporting dysphagia as an adverse event than patients prescribed many other medicines. This increase in dysphagia occurrence may be attributed to the dual inhibition of both acetylcholinesterase and butyrylcholinesterase.
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Affiliation(s)
- Kun Bu
- Department of Mathematics & Statistics, College of Art and Science, University of South Florida, Tampa, FL, USA
| | - Devashru Patel
- College of Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | - Robert Morris
- Department of Pharmaceutical Science, Taneja College of Pharmacy, University of South Florida, Tampa, FL, USA
- Department of Biostatistics & Epidemiology, College of Public Health, University of South Florida, Tampa, FL, USA
| | - Weiru Han
- Department of Mathematics & Statistics, College of Art and Science, University of South Florida, Tampa, FL, USA
| | - Gibret Umeukeje
- Department of Pharmaceutical Science, Taneja College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Tianrui Zhu
- Department of Pharmaceutical Science, Taneja College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Feng Cheng
- Department of Pharmaceutical Science, Taneja College of Pharmacy, University of South Florida, Tampa, FL, USA
- Department of Biostatistics & Epidemiology, College of Public Health, University of South Florida, Tampa, FL, USA
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24
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Gee S, Almeida V, Hughes A, McMullen I, Taylor D. Reasons for admission to a general medical hospital for patients taking clozapine. Ther Adv Psychopharmacol 2022; 12:20451253221136753. [PMID: 36582490 PMCID: PMC9793060 DOI: 10.1177/20451253221136753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Clozapine is associated with a diverse range of side effects. In addition, patients prescribed clozapine commonly suffer with medical comorbidities. OBJECTIVES This study aimed to characterise patients prescribed clozapine who required medical admission, understand reasons for admission, identify areas for interventions to prevent future admission and describe clozapine management during the inpatient stay. DESIGN We conducted a retrospective analysis of patients prescribed clozapine who were admitted to a general medical hospital in a 12-month period. METHOD Data were collected using electronic drug charts and notes. RESULTS In total, 114 clozapine patients were hospitalised. Twenty-eight patients (25%) were admitted because of infection, 12 (11%) were elective admissions and 12 (11%) had gastrointestinal problems. Most patients admitted were Black (54%) and half were female. Few changes were made to clozapine dosing on admission or during the inpatient stay. Most patients had been taking clozapine for many years at the point of admission, the majority were able to continue taking it for the duration of their medical treatment and were discharged on the same dose they were taking prior to admission. Clozapine plasma concentrations were not consistently measured with only 18 (16%) patients having one or more plasma concentrations determined during their admission. The median clozapine plasma concentration on admission was 0.48 mg/L (nor-clozapine 0.21 mg/L), with a range of 0.09 to 3.9 mg/L. Three patients were admitted to the intensive care unit during their admission; all were discharged on clozapine. Four patients died; one from lung adenocarcinoma, one bowel obstruction, one cardiac arrest and one chest sepsis. In total, 27 patients (23%) had their clozapine stopped on admission, 6 (22% of this group) unintentionally. CONCLUSIONS Our study found that the most common reason for admission for patients taking clozapine was infection. Plasma concentrations were not measured routinely despite clozapine having a narrow therapeutic index and enhanced potential for toxicity in the medically unwell patient.
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Affiliation(s)
- Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Vasco Almeida
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Adam Hughes
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Isabel McMullen
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
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25
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Zhuo C, Xu Y, Wang H, Zhou C, Liu J, Yu X, Shao H, Tian H, Fang T, Li Q, Chen J, Xu S, Ma X, Yang W, Yao C, Li B, Yang A, Chen Y, Huang G, Lin C. Clozapine induces metformin-resistant prediabetes/diabetes that is associated with poor clinical efficacy in patients with early treatment-resistant schizophrenia. J Affect Disord 2021; 295:163-172. [PMID: 34464878 DOI: 10.1016/j.jad.2021.08.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Two distinct subtypes of treatment-resistant schizophrenia (TRS) have been recently reported, including early-treatment resistance (E-TR) and late-treatment resistance (L-TR). This study was to assess clozapine-induced metformin-resistant prediabetes/diabetes and its correlation with clinical efficacy in schizophrenia E-TR subtype. METHODS This prospective cohort study enrolled 230 patients with schizophrenia E-TR subtype and they were treated with adequate doses of clozapine for 16 weeks, during which patients with prediabetes/diabetes were assigned to receive add-on metformin. The main outcomes and measures included incidence of clozapine-induced prediabetes/diabetes and metformin-resistant prediabetes/diabetes, and the efficacy of clozapine as assessed by the Positive and Negative Syndrome Scale (PANSS) score. RESULTS Clozapine-induced prediabetes/diabetes occurred in 76.52% of patients (170 prediabetes and 6 diabetes), of which the blood sugar of 43 (24.43%) patients was controlled with metformin. Despite add-on metformin, 47.06% (74/170) of prediabetes patients progressed to diabetes. In total, the incidence of clozapine-induced metformin-resistant prediabetes/diabetes was 75.57% (133/176). On completion of 16-week clozapine treatment, 16.52% (38/230) patients showed clinical improvement with PANSS scores of ≥50% declining. Furthermore, clozapine-induced prediabetes/diabetes was significantly correlated with the poor clinical efficacy of clozapine for schizophrenia E-TR subtype. CONCLUSIONS The incidence of clozapine-induced metformin-resistant prediabetes/diabetes was considerably high in the schizophrenia E-TR subtype. Clozapine-induced metformin-resistant prediabetes/diabetes represents an independent risk factor that adversely affects the clinical efficacy of clozapine for the schizophrenia E-TR subtype. This study provided new evidence for re-evaluating the use of clozapine for TRS, especially E-TR subtype, and the use of metformin for the glycemic control of clozapine-induced prediabetes/diabetes.
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Affiliation(s)
- Chuanjun Zhuo
- Key Laboratory of Multiple Organ Damages of Major Psychoses (MODMP_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China.
| | - Yong Xu
- Department of Psychiatry, First Clinical Medical College, First Hospital of Shanxi Medical University, Taiyuan 030000, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, 100191, China
| | - Chunhua Zhou
- Department of Pharmacoloy, The First Hospital of Hebei Medical University, Shijiazhuang 05000, Hebei Province, China
| | - Jian Liu
- Clinical Laboratory, Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Xiaocui Yu
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Clinical Laboratory, Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Hailin Shao
- Key Laboratory of Multiple Organ Damages of Major Psychoses (MODMP_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China
| | - Hongjun Tian
- Key Laboratory of Multiple Organ Damages of Major Psychoses (MODMP_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China
| | - Tao Fang
- Key Laboratory of Multiple Organ Damages of Major Psychoses (MODMP_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China
| | - Qianchen Li
- Department of Pharmacoloy, The First Hospital of Hebei Medical University, Shijiazhuang 05000, Hebei Province, China
| | - Jiayue Chen
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Shuli Xu
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Xiaoyan Ma
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Weiliang Yang
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Cong Yao
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key Laboratory of Psychiatry Neuroimaging-genetics and Co-morbidity (PNGC_Lab), Tianjin Medical University Clinical Hospital of Mental Health, Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin 300222, China
| | - Bo Li
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Department of Psychiatry, Tianjin Kangtai Mental Health Hospital, Tianjin 300014, China
| | - Anqu Yang
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Department of Psychiatry, Tianjin Kangtai Mental Health Hospital, Tianjin 300014, China
| | - Yuhui Chen
- National Center of Endocrine and Metabolic Disease Comprehensive Management (MMC), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Key laboratory of Real Time Brain Circuits Tracing of Neurology and Psychiatry (RTBNB_Lab), Tianjin fourth center Hospital, Tianjin Medical Affiliated Tianjin Fourth Central Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China; Department of Psychiatry, Tianjin Kangtai Mental Health Hospital, Tianjin 300014, China
| | - Guoyong Huang
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, 325000
| | - Chongguang Lin
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, 325000
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26
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Adanty C, Shakeri A, Strauss J, Graff A, De Luca V. Head-to-head comparison of various antipsychotic agents on genome-wide methylation in schizophrenia. Pharmacogenomics 2021; 23:5-14. [PMID: 34787483 DOI: 10.2217/pgs-2021-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To explore possible differences in genome-wide methylation between schizophrenia patients who consume various antipsychotics. Methods: We compared DNA methylation in leukocytes between the following cohorts: clozapine (n = 19) versus risperidone (n = 19), clozapine (n = 12) versus olanzapine (n = 12), clozapine (n = 9) versus quetiapine (n = 9) and clozapine (n = 33) versus healthy controls (n = 33). Subjects were matched for age, sex, ethnicity, smoking status and leukocyte proportions. Results: No single CpG site reached genome-wide significance for clozapine versus risperidone/olanzapine/quetiapine. For clozapine versus quetiapine, one significantly differentially methylated region was found - ch5: 176797920-176798049 (fwer = 0.075). Clozapine versus healthy controls yielded thousands of significantly differentially methylated CpG sites. Conclusions: Establishing antipsychotic induced genome-wide methylation patterns will further elucidate the biological and clinical effects of antipsychotic administration.
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Affiliation(s)
| | - Ahmad Shakeri
- Centre for Addiction & Mental Health, Toronto, Canada
| | - John Strauss
- Centre for Addiction & Mental Health, Toronto, Canada
| | - Ariel Graff
- Centre for Addiction & Mental Health, Toronto, Canada
| | - Vincenzo De Luca
- Centre for Addiction & Mental Health, Toronto, Canada.,St Michael's Hospital, Toronto, Canada
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27
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Antipsychotic-Related Fatal Poisoning, England and Wales, 1993-2019: The Impact of Second-Generation Antipsychotics. J Clin Psychopharmacol 2021; 41:650-657. [PMID: 34668874 DOI: 10.1097/jcp.0000000000001479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Deaths from antipsychotic (AP) poisoning have increased in England and Wales despite restriction of the use of thioridazine in 2000. METHODS We analyzed data from the Office for National Statistics drug-related death database, England and Wales, 1993-2019, to investigate fatal AP poisoning. RESULTS There were 2286 deaths (62% male patients). Annual numbers of intentional AP-related fatal poisonings (suicides) were relatively stable (1993, 35; 2019, 44; median, 44; range, 30-60). Intentional overdose deaths involving clozapine (96 male, 25 female) increased from 1 in 1994 to 5 in 2003 and have since remained relatively constant (median, 6; range, 3-10 per annum). Unintentional second-generation AP-related fatal poisonings have increased steadily since 1998, featuring in 828 (74%) of all unintentional, AP-related fatal poisonings in the period studied (2019, 89%). There were 181 unintentional clozapine-related deaths, (107 [59%] alone without other drugs ± alcohol) as compared with 291 quetiapine-related deaths (86 [30%] alone without other drugs ± alcohol) and 314 unintentional olanzapine-related deaths (77 [25%] alone without other drugs ± alcohol). Some 75% of all unintentional clozapine- and olanzapine-related deaths were of male patients (78% and 73%, respectively) as compared with 58% of unintentional quetiapine-related fatal poisonings. Clozapine now features prominently in intentional and in unintentional AP-related fatal poisoning in England and Wales. Deaths of male patients predominate in both categories. There were also 77 and 86 deaths attributed to unintentional poisoning with olanzapine and with quetiapine, respectively, in the absence of other drugs. CONCLUSIONS More effort is needed to prevent unintentional deaths not only from clozapine but also from olanzapine and quetiapine.
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28
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Pardiñas AF, Owen MJ, Walters JTR. Pharmacogenomics: A road ahead for precision medicine in psychiatry. Neuron 2021; 109:3914-3929. [PMID: 34619094 DOI: 10.1016/j.neuron.2021.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
Psychiatric genomics is providing insights into the nature of psychiatric conditions that in time should identify new drug targets and improve patient care. Less attention has been paid to psychiatric pharmacogenomics research, despite its potential to deliver more rapid change in clinical practice and patient outcomes. The pharmacogenomics of treatment response encapsulates both pharmacokinetic ("what the body does to a drug") and pharmacodynamic ("what the drug does to the body") effects. Despite early optimism and substantial research in both these areas, they have to date made little impact on clinical management in psychiatry. A number of bottlenecks have hampered progress, including a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. Nonetheless, advances in genomics and health informatics present distinct opportunities for psychiatric pharmacogenomics to enter a new and productive phase of research discovery and translation.
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Affiliation(s)
- Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK
| | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK.
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK
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29
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Edinoff AN, Fort JM, Woo JJ, Causey CD, Burroughs CR, Cornett EM, Kaye AM, Kaye AD. Selective Serotonin Reuptake Inhibitors and Clozapine: Clinically Relevant Interactions and Considerations. Neurol Int 2021; 13:445-463. [PMID: 34564289 PMCID: PMC8482107 DOI: 10.3390/neurolint13030044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/29/2021] [Accepted: 08/12/2021] [Indexed: 12/21/2022] Open
Abstract
The monoamine hypothesis of depression attributes the symptoms of major depressive disorders to imbalances of serotonin, noradrenaline, and dopamine in the limbic areas of the brain. The preferential targeting of serotonin receptor (SERT) by selective serotonin reuptake inhibitors (SSRIs) has offered an opportunity to reduce the range of these side effects and improve patient adherence to pharmacotherapy. Clozapine remains an effective drug against treatment-resistant schizophrenia, defined as failing treatment with at least two different antipsychotic medications. Patients with schizophrenia who display a constellation of negative symptoms respond poorly to antipsychotic monotherapy. Negative symptoms include the diminution of motivation, interest, or expression. Conversely to the depressive symptomology of interest presently, supplementation of antipsychotics with SSRIs in schizophrenic patients with negative symptoms lead to synergistic improvements in the function of these patients. Fluvoxamine is one of the most potent inhibitors of CYP1A2 and can lead to an increase in clozapine levels. Similar increases in serum clozapine were detected in two patients taking sertraline. However, studies have been contradictory as well, showing no such increases, which are worrying. Clinicians should be aware that clozapine levels should be monitored with any coadministration with SSRIs.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71103, USA
| | - Juliana M Fort
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71103, USA
| | - Joshua J Woo
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Christopher D Causey
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Caroline R Burroughs
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport, Shreveport, LA 71103, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport, Shreveport, LA 71103, USA
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30
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Kaikoushi K, Karanikola M, Middleton N, Bella E, Chatzittofis A. Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics. BJPsych Open 2021; 7:e149. [PMID: 34747353 PMCID: PMC8388008 DOI: 10.1192/bjo.2021.982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. AIMS We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. METHOD This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. RESULTS Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. CONCLUSIONS A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.
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Affiliation(s)
- Katerina Kaikoushi
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus; and Cyprus mental Health Services, Famagusta, Cyprus
| | - Maria Karanikola
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | - Nicos Middleton
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | | | - Andreas Chatzittofis
- Medical School, University of Cyprus, Cyprus; and Department of Clinical Sciences, Umeå University, Umeå, Sweden
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31
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Gee S, McMullen I, Wyke C, Yeoh SY, Taylor D. Intramuscular clozapine in the acute medical hospital: Experiences from a liaison psychiatry team. SAGE Open Med Case Rep 2021; 9:2050313X211004796. [PMID: 34094561 PMCID: PMC8141995 DOI: 10.1177/2050313x211004796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/19/2022] Open
Abstract
We present two cases demonstrating safe and effective use of intramuscular clozapine for patients who are physically unwell in acute medical care settings. Both patients described were admitted to inpatient medical care units and required treatment with clozapine to control their psychotic symptoms, but were unable or unwilling to take oral clozapine. We describe the use of intramuscular clozapine in these patients, including dosing decisions, administration routes and frequency of dosing. Outcome was measured by a reduction in psychotic symptoms, sufficient to allow treatment for physical illness. Both patients successfully received intramuscular clozapine, allowing timely treatment of their physical health conditions. There were no adverse events, and significant improvement in their mental health presentations was achieved. We have shown that intramuscular clozapine is a safe and effective treatment for patients with serious mental health illness in the acute medical hospital.
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Affiliation(s)
- Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Isabel McMullen
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Clementine Wyke
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Su Ying Yeoh
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Sciences, King's College London, London, UK
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