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Kar A, Nutting T, Ikram M, Sullivan C. The clozapine conundrum: Navigating neutropenia and the pursuit of effective care in treatment-resistant schizophrenia. Int J Psychiatry Med 2024; 59:536-544. [PMID: 37971414 DOI: 10.1177/00912174231214647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Background: This case explores the challenges encountered in managing treatment-resistant paranoid schizophrenia, focusing on the limitations of using clozapine due to the risk of neutropenia. The United Kingdom Clozapine Patient Monitoring Service (UK CPMS) and its eligibility criteria are discussed, highlighting the potential benefits of expanding access to clozapine for patients who could potentially benefit from this medication. The integration of clozapine genetic testing as a personalized approach is explored, emphasizing the importance of identifying patients with a favorable genetic profile for clozapine response.Methods: Case report.Results: The case presentation of Mr. X exemplifies the difficulties faced in managing treatment-resistant schizophrenia when access to clozapine is restricted, leading to persistent negative symptoms.Conclusion: The article underscores the importance of innovative solutions and personalized care to enhance the treatment outcomes for patients with treatment-resistant paranoid schizophrenia. It acknowledges that certain restrictions of clozapine use may limit the effective management of patients with this condition.
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Affiliation(s)
- Anindya Kar
- Wotton Lawn Hospital, Gloucestershire Health and Care NHS Foundation Trust, UK
| | - Thomas Nutting
- Wotton Lawn Hospital, Gloucestershire Health and Care NHS Foundation Trust, UK
| | - Mohammad Ikram
- Wotton Lawn Hospital, Gloucestershire Health and Care NHS Foundation Trust, UK
| | - Charles Sullivan
- Wotton Lawn Hospital, Gloucestershire Health and Care NHS Foundation Trust, UK
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Oloyede E, Bachmann CJ, Dzahini O, Lopez Alcaraz JM, Singh SD, Vallianatu K, Funk B, Whiskey E, Taylor D. Identifying clinically relevant agranulocytosis in people registered on the UK clozapine Central Non-Rechallenge Database: retrospective cohort study. Br J Psychiatry 2024:1-8. [PMID: 39149780 DOI: 10.1192/bjp.2024.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Clozapine is the most effective antipsychotic for treatment-resistant psychosis. However, clozapine is underutilised in part because of potential agranulocytosis. Accumulating evidence indicates that below-threshold haematological readings in isolation are not diagnostic of life-threatening clozapine-induced agranulocytosis (CIA). AIMS To examine the prevalence and timing of CIA using different diagnostic criteria and to explore demographic differences of CIA in patients registered on the UK Central Non-Rechallenge Database (CNRD). METHOD We analysed data of all patients registered on the UK Clozaril® Patient Monitoring Service Central Non-Rechallenge Database (at least one absolute neutrophil count (ANC) < 1.5 × 109/L and/or white blood cell count < 3.0 × 109/L) between May 2000 and February 2021. We calculated prevalence rates of agranulocytosis using threshold-based and pattern-based criteria, stratified by demographic factors (gender, age and ethnicity). Differences in epidemiology based on rechallenge status and clozapine indication were explored. The proportion of patients who recorded agranulocytosis from a normal ANC was explored. RESULTS Of the 3029 patients registered on the CNRD with 283 726 blood measurements, 593 (19.6%) were determined to have threshold-based agranulocytosis and 348 (11.4%) pattern-based agranulocytosis. In the total sample (75 533), the prevalence of threshold-based agranulocytosis and pattern-based agranulocytosis was 0.8% and 0.5%, respectively. The median time to threshold-based agranulocytosis was 32 weeks (IQR 184) and 15 (IQR 170) weeks for pattern-based agranulocytosis. Among age groups, the prevalence of pattern-based agranulocytosis and threshold-based agranulocytosis was highest in the >48 age group. Prevalence rates were greatest for White (18%) and male individuals (13%), and lowest for Black individuals (0.1%). The proportion of people who were determined to have pattern-based agranulocytosis without passing through neutropenia was 70%. CONCLUSIONS Threshold-based definition of agranulocytosis may over-diagnose CIA. Monitoring schemes should take into consideration neutrophil patterns to correctly identify clinically relevant CIA. In marked contrast to previous studies, CIA occurred least in Black individuals and most in White individuals.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, Maudsley Hospital, London, UK
- Department of Psychiatry, University of Oxford, UK
| | | | - Olubanke Dzahini
- Pharmacy Department, Maudsley Hospital, London, UK
- Institute of Pharmaceutical Sciences, King's College London, UK
| | | | - Shaurya Dev Singh
- Institute of Information Science, Leuphana University, Lüneburg, Germany
| | | | - Burkhardt Funk
- Institute of Information Science, Leuphana University, Lüneburg, Germany
| | - Eromona Whiskey
- Pharmacy Department, Maudsley Hospital, London, UK
- National Psychosis Unit, Bethlem Royal Hospital, Beckenham, UK
| | - David Taylor
- Pharmacy Department, Maudsley Hospital, London, UK
- Institute of Pharmaceutical Sciences, King's College London, UK
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Silva E, Legge S, Casetta C, Whiskey E, Oloyede E, Gee S. Understanding clozapine-related blood dyscrasias. Developments, genetics, ethnicity and disparity: it's a CIN. BJPsych Bull 2024:1-6. [PMID: 38828731 DOI: 10.1192/bjb.2024.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Clozapine remains the gold standard intervention for treatment-resistant schizophrenia; however, it remains underused, especially for some minority groups. A significant impediment is concern about propensity to neutropenia. The aim of this article is to provide an update on current knowledge relating to: the pattern and incidence of severe blood dyscrasias; the effectiveness of current monitoring regimes in reducing harm; the mechanisms of and the distinctions between clozapine-induced neutropenia and agranulocytosis; benign ethnic neutropenia; and changes to the monitoring thresholds in the USA and other international variations. These all have implications for the practical use of clozapine; specifically, how barriers to initiating, maintaining and restarting clozapine can be understood and in many cases overcome, especially for patients from minority groups, potentially with simpler approaches than the use of lithium or G-CSF.
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Affiliation(s)
| | | | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK
- University of Oxford, Oxford, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
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Verdoux H, Quiles C, de Leon J. Risks and benefits of clozapine and lithium co-prescribing: A systematic review and expert recommendations. Schizophr Res 2024; 268:233-242. [PMID: 37002013 DOI: 10.1016/j.schres.2023.03.032] [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: 03/01/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES To identify the risks and benefits of clozapine‑lithium co-prescription. METHODS Articles published in English or French were identified with a MEDLINE, Web of Sciences and PsycINFO search, from inception through January 2023, using the term 'clozapine' in combination with 'lithium'. Data were synthesized narratively. RESULTS Of the 67 articles included in the review, more than half (n = 38, 56.7 %) were focused on clozapine-related blood dyscrasia. A body of evidence drawn from case reports and retrospective chart studies highlights the potential benefits of lithium prescription for clozapine-related neutropenia, since this strategy may avoid clozapine discontinuation or allow its rechallenge. The most documented adverse drug reactions (ADRs) associated with clozapine‑lithium co-prescription are neurotoxic events, which may be prevented or detected early by clinical, electroencephalographic and therapeutic drug monitoring. Causality assessment cannot be established for other reported ADRs occurring during clozapine‑lithium co-prescription. The benefits of the combined prescription on psychotic and/or mood symptoms are poorly documented. CONCLUSION The risks and benefits of clozapine‑lithium co-prescription require further exploration as the combination might significantly contribute to reducing underprescription or premature discontinuation of clozapine.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain; Psychiatry and Neurosciences Research Group (CTS-549), USA
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5
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Schulte PFJ, Veerman SRT, Bakker B, Bogers JPAM, Jongkind A, Cohen D. Risk of clozapine-associated agranulocytosis and mandatory white blood cell monitoring: Can the regulations be relaxed? Schizophr Res 2024; 268:74-81. [PMID: 37770377 DOI: 10.1016/j.schres.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023]
Abstract
After the introduction of clozapine eight Finnish patients died after developing agranulocytosis. Clozapine was withdrawn from the market and only reintroduced with strict mandatory white blood cell monitoring as long as treatment lasts and thresholds at which clozapine must be discontinued definitively. The fear of agranulocytosis and the need for intensive blood monitoring is the single most important barrier for prescribers and patients alike and leads to underprescription of the only effective and approved medication for treatment-resistant schizophrenia. We summarize evidence that the risk of agranulocytosis is smaller than perceived at the time of reintroduction, is concentrated in the first 18 weeks of treatment, is not greater than with other antipsychotics thereafter and that frequent blood monitoring has not demonstrably decreased the rate of agranulocytosis. Therefore we propose 1) mandatory monitoring of the absolute neutrophil count (ANC) exclusively during the first 18 weeks of clozapine treatment, 2) that thereafter the prescriber and the well-informed patient decide together about further monitoring frequency, 3) that clozapine treatment must be stopped if the ANC falls below 1.0 × 109/L. Continuation of clozapine or a rechallenge are possible if prescriber and patient determine that the benefits outweigh the risks. 4) National registries which control the haematologic monitoring are unnecessary and do not help to reduce clozapine-induced agranulocytosis. They should at least be restricted to the first 18 weeks of clozapine use.
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Affiliation(s)
- Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Selene R T Veerman
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Bert Bakker
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands
| | - Jan P A M Bogers
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands; High Care Clinics, Mental Health Service Rivierduinen, Oegstgeest, the Netherlands.
| | - Amy Jongkind
- Dutch Clozapine Collaboration Group, Castricum, the Netherlands; Early Detection and Intervention Team, Reinier van Arkel, 's-Hertogenbosch, the Netherlands.
| | - Dan Cohen
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
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Wu S, Powell V, Chintoh A, Alarabi M, Agarwal SM, Remington G. Safety of BEN guidelines in clozapine treatment: A Canadian perspective. Schizophr Res 2024; 264:451-456. [PMID: 38262312 DOI: 10.1016/j.schres.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/29/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE Unidentified benign ethnic neutropenia (BEN) has been recognized as a factor contributing to clozapine underutilization and discontinuation. Guidelines were implemented to accommodate BEN in Canada, and our main objective was to evaluate clozapine's safety in a sample of Canadian psychiatric patients with BEN. METHOD A retrospective chart review was conducted at the Centre for Addiction and Mental Health, Toronto, Canada. Through the clozapine clinic registry, participants were identified who (i) received clozapine using the approved BEN guidelines for hematological monitoring, and (ii) had at least one complete blood count pre- and post-clozapine initiation. RESULTS Our sample population was comprised of 41 BEN patients who were African-Caribbean (49 %), African (34 %), African-North American (12 %), Middle Eastern (2 %), and Indian-Caribbean (2 %). There was a significant reduction in hematological alerts for these patients while monitored under BEN guidelines (p < 0.001). The mean within-patient ANC value was not significantly different one year after clozapine initiation compared to the pre-clozapine baseline (p = 0.069). None of the patients discontinued clozapine for hematological reasons. CONCLUSIONS Findings demonstrated that patients monitored under the modified hematological guidelines for BEN can be safely treated with clozapine. These findings have important clinical ramifications as increased implementation of BEN guidelines may allow for broader use of clozapine.
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Affiliation(s)
- Sally Wu
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Temerty Faculty of Medicine, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Valerie Powell
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
| | - Araba Chintoh
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Mohammed Alarabi
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia
| | - Sri Mahavir Agarwal
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Temerty Faculty of Medicine, Institute of Medical Sciences, University of Toronto, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Temerty Faculty of Medicine, Institute of Medical Sciences, University of Toronto, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, ON, Canada.
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Lock SK, Legge SE, Kappel DB, Willcocks IR, Helthuis M, Jansen J, Walters JTR, Owen MJ, O'Donovan MC, Pardiñas AF. Mediation and longitudinal analysis to interpret the association between clozapine pharmacokinetics, pharmacogenomics, and absolute neutrophil count. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:74. [PMID: 37853043 PMCID: PMC10585000 DOI: 10.1038/s41537-023-00404-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
Clozapine is effective at reducing symptoms of treatment-resistant schizophrenia, but it can also induce several adverse outcomes including neutropenia and agranulocytosis. We used linear mixed-effect models and structural equation modelling to determine whether pharmacokinetic and genetic variables influence absolute neutrophil count in a longitudinal UK-based sample of clozapine users not currently experiencing neutropenia (N = 811). Increased daily clozapine dose was associated with elevated neutrophil count, amounting to a 133 cells/mm3 rise per standard deviation increase in clozapine dose. One-third of the total effect of clozapine dose was mediated by plasma clozapine and norclozapine levels, which themselves demonstrated opposing, independent associations with absolute neutrophil count. Finally, CYP1A2 pharmacogenomic activity score was associated with absolute neutrophil count, supporting lower neutrophil levels in CYP1A2 poor metabolisers during clozapine use. This information may facilitate identifying at-risk patients and then introducing preventative interventions or individualised pharmacovigilance procedures to help mitigate these adverse haematological reactions.
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Affiliation(s)
- Siobhan K Lock
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Sophie E Legge
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Djenifer B Kappel
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Isabella R Willcocks
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | - John Jansen
- Leyden Delta B.V., Nijmegen, The Netherlands
| | - James T R Walters
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael J Owen
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael C O'Donovan
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Antonio F Pardiñas
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK.
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Wagner E, Siskind D, Falkai P, Howes O, Correll C, Lee J, Honer WG, Kane JM, Fernandez-Egea E, Barnes TRE, Hasan A. Clozapine Optimization: A Delphi Consensus Guideline From the Treatment Response and Resistance in Psychosis Working Group. Schizophr Bull 2023; 49:962-972. [PMID: 36943247 PMCID: PMC10318876 DOI: 10.1093/schbul/sbad030] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND HYPOTHESIS There is limited evidence to guide the approaches to clozapine treatment. Accordingly, an international initiative was undertaken with the aim of developing consensus recommendations for the optimization of clozapine monotherapy. STUDY DESIGN We conducted an online Delphi survey among members of the Treatment Response and Resistance in Psychosis (TRRIP) working group comprising experts from twenty-nine countries. The threshold criterion for a consensus recommendation was ≥ 75% agreement ("agree" and "strongly agree" responses) on a question. Agreement of ≥ 50% but < 75% in a second or third Delphi round was deemed to provide guidance. STUDY RESULTS Forty-nine (first round), 32 (second round), and 48 (third round) of the 91 current TRRIP members participated. Expert recommendations at ≥ 75% comprised second-line treatment with clozapine in cases of persistent positive symptoms with co-occurring extrapyramidal symptoms, tardive dyskinesia, or suicidality/aggression. There was considerable disagreement on myocarditis screening parameters. The management of somatic and neuropsychiatric adverse drug reactions warrants further research for more evidence-based recommendations. Rechallenge with clozapine was recommended for eosinophilia, sinus tachycardia and fever and guidance (agreement ≥ 50%) was reached for pneumonia and thrombocytopenia. CONCLUSIONS Given the limited evidence available, this consensus-based series of recommendations and guidance statements supports clinical decision-making to optimize clozapine monotherapy and provides guidance for future research in treatment-resistant schizophrenia.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
- Mobile Intensive Rehabilitation Team, Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Christoph Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin, Berlin, Germany
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore
- Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - William G Honer
- Department of Psychiatry, Institute of Mental Health, The University of British Columbia, Vancouver, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
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Oloyede E, Dunnett D, Taylor D, Clark I, MacCabe JH, Whiskey E, Onwumere J. The lived experience of clozapine discontinuation in patients and carers following suspected clozapine-induced neutropenia. BMC Psychiatry 2023; 23:413. [PMID: 37291505 PMCID: PMC10249299 DOI: 10.1186/s12888-023-04902-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Clozapine is the treatment of choice in refractory psychosis. In most countries, clozapine must be stopped indefinitely if white blood cells fall below a defined threshold during routine monitoring. Despite evidence of severe adverse consequences of clozapine discontinuation, published accounts on the lived experiences and perspectives of patients and carers are scarce. METHOD We completed semi-structured interviews with patients (n = 4) and family carers (n = 4) on experiences of clozapine cessation following suspected drug-induced neutropenia. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS The two overarching themes comprised:(i) stress of clozapine below threshold neutrophil results and (ii) patient and carer priorities. CONCLUSIONS There is a suggested need for evidence-based pharmacological and psychological approaches to support patients and carers after clozapine cessation. Such approaches will minimise the potentially negative physical and emotional sequela in the aftermath of a below threshold neutrophil result and reduce the likelihood of experiencing additional health and social inequalities after clozapine discontinuation.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK.
- University of Oxford, Department of Psychiatry , Warneford, United Kingdom.
| | - Danielle Dunnett
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
| | - Ivana Clark
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, King's College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, London, SE1 9NH, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Juliana Onwumere
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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10
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Bertoli S, Casetta C, Giordano B, D'Agostino A. A national pharmacovigilance study of haematological adverse drug reactions to clozapine vs other second-generation antipsychotics in Italy. Schizophr Res 2023; 257:25-26. [PMID: 37244166 DOI: 10.1016/j.schres.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Sara Bertoli
- Hospital Pharmacy, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cecilia Casetta
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Barbara Giordano
- Department of Mental Health and Addiction, ASST Santi Paolo e Carlo, Milan, Italy
| | - Armando D'Agostino
- Department of Mental Health and Addiction, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, Università degli Studi di Milano, Italy.
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Oloyede E, Blackman G, Mantell B, Harris E, Williams J, Taylor D, MacCabe J, McGuire P. What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:26. [PMID: 37117237 PMCID: PMC10147630 DOI: 10.1038/s41537-023-00353-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/03/2023] [Indexed: 04/30/2023]
Abstract
Clozapine is the most effective medication for treatment-resistant psychosis, but evidence points to substantial underuse, especially within early intervention psychosis (EIP) services. We explored clinicians' views on perceived barriers and facilitators to offering patients clozapine within EIP services. A cross-sectional survey was distributed electronically to clinicians practising in EIP services across England. A mixed methods approach was used to assess barriers to clozapine, and attitudes and opinions concerning clozapine underutilisation. Based on the barriers identified in the literature, clinicians were asked to rate each one (scale:1-7) based on importance, with a higher score indicating higher importance. Clinicians were also asked open-ended questions on barriers to clozapine and how access can be improved in EIP services. Quantitative data were analysed using descriptive and inferential statistics, and qualitative responses were analysed thematically. One hundred and nineteen EIP clinicians from 35 services in England completed the survey. In total, 37% (n = 45) of clinicians perceived that clozapine was under-prescribed in their EIP service. The most important barrier to utilising clozapine were patient concerns with side effects, followed by monitoring requirements and clinician concerns with side effects. Thematic analysis identified 17 perceived barriers, which were grouped into three major themes: administrative (5 subthemes), clinician-related (6 subthemes), and patient-related (6 subthemes). Perceived facilitators to improving clozapine use were greater training, improved resources, and optimised monitoring. The main barriers to clozapine in EIP services, as identified by clinicians, are patient concerns regarding side effects and monitoring requirements. Identified facilitators for improved clozapine use include clinician training, improved resources, guidelines, and point-of-care testing.
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Affiliation(s)
- Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK.
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- Department of Psychiatry, University of Oxford, Warneford, UK.
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychiatry, University of Oxford, Warneford, UK
| | - Bethany Mantell
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Eleanor Harris
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Julie Williams
- Health Service and Population Research Department, Centre for Implementation Science, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - James MacCabe
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Philip McGuire
- Department of Psychiatry, University of Oxford, Warneford, UK
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Saito T, Usui T, Inada H, Miyawaki I, Mizuno K, Ikeda M, Iwata N. Clozapine-specific proliferative response of peripheral blood-derived mononuclear cells in Japanese patients with clozapine-induced agranulocytosis. J Psychopharmacol 2022; 36:1087-1094. [PMID: 35861221 DOI: 10.1177/02698811221112937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although clozapine-induced granulocytopenia (CIG) is less severe than clozapine-induced agranulocytosis (CIA), and some patients with CIG may not go on to develop serious complications, clozapine is discontinued in cases of both CIA and CIG. Understanding the pathogenic mechanisms of CIA/CIG could provide better management of clozapine therapy. Recently, as a mechanistic insight into adaptive immune systems, European groups reported clozapine-specific proliferative responses and clozapine-specific T cells using blood taken from patients with CIA and/or CIG. AIMS The aims of our study are to support this mechanistic evidence and to investigate the difference in the lymphocyte response to clozapine between patients with CIG and those with CIA. METHODS Lymphocyte stimulation tests (LSTs) were conducted using CD25-positive cell-depleted peripheral blood-derived mononuclear cells (PBMCs) isolated from blood of four Japanese patients with CIA, four patients with CIG, and nine clozapine-tolerant subjects. RESULTS Three of four patients with CIA and one of four patients with CIG showed proliferative responses to clozapine with a stimulation index of greater than 2. In contrast, none of the nine clozapine-tolerant subjects showed any response to clozapine. Olanzapine did not stimulate PBMCs of patients with CIA, patients with CIG, or clozapine-tolerant subjects. CONCLUSIONS Clozapine- and CIA-specific lymphocyte reactions in a Japanese population provided supportive evidence that the pathogenesis of CIA is based on adaptive immune reactions. In addition, patients with CIG who show a positive response to an LST may at the very least not be chosen for clozapine-rechallenge and further prospective studies are desirable to verify this hypothesis.
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Affiliation(s)
- Takeo Saito
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toru Usui
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Hiroshi Inada
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Izuru Miyawaki
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | | | - Masashi Ikeda
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
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Oloyede E, Whiskey E, Casetta C, Dzahini O, Dunnett D, Gandhi S, Gaughran F, Shergill S, McGuire P, MacCabe JH, Taylor D. Relaxation of the criteria for entry to the UK Clozapine Central Non-Rechallenge Database: a modelling study. Lancet Psychiatry 2022; 9:636-644. [PMID: 35772414 DOI: 10.1016/s2215-0366(22)00188-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/22/2022] [Accepted: 05/04/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clozapine is uniquely effective in treatment-resistant psychosis. In the UK, patients must discontinue clozapine indefinitely if they are placed on the Central Non-Rechallenge Database (CNRD) after their haematological parameters fall below particular thresholds. Under exceptional circumstances, patients can be rechallenged on clozapine under an off-licence agreement. In the USA in 2015, restrictive practice was discontinued to allow greater flexibility for clozapine maintenance. The absolute neutrophil count leading to treatment interruption was lowered from less than 1·5 × 109/L to less than 1·0 × 109/L and platelet and white cell count monitoring were ceased. We aimed to investigate the implications of a similar policy change on clozapine use in the UK. METHODS This was a modelling study of all patients registered on the UK CNRD. First, we determined the proportion of patients placed on the database in the UK who would have had to discontinue clozapine treatment under the US Food and Drug Administration (FDA) criteria. Second, we compared the haematological characteristics of patients who did or did not meet FDA criteria for discontinuing clozapine, including the time to registration from clozapine initiation and the proportion of cases of severe neutropenia at registration. Third, we investigated the success rates of clozapine re-challenge for patients that had been placed on the CNRD. Successful rechallenge was defined as no recurrence of CNRD registration. FINDINGS Between May 2, 2002 and March 1, 2021, 3731 patients were placed on the CNRD, with a mean age of 47 years (SD 15), including 1420 (38%) women and 2311 (62%) men, of whom 3089 (83%) were White, 360 (10%) were Black, 190 (5%) were Asian, and 92 (2%) were classified as other. 566 (15%) of 3731 patients met the equivalent criteria for clozapine discontinuation under the FDA guidelines. The median time to CNRD registration from clozapine initiation was 1·6 years (IQR 0·2-4·9). Data for 519 rechallenged patients were examined; 419 (81%) were successful. Clozapine rechallenge success rates were broadly similar between individuals who did not meet the US CNRD registration criteria (36 [78%] of 46) and those who did meet the criteria (383 [81%] of 473). INTERPRETATION Implementing the revised FDA monitoring criteria in the UK would substantially reduce clozapine discontinuation for haematological reasons, which would greatly improve the mental health outcomes of these patients without having a major effect on their physical health. FUNDING None.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Cecilia Casetta
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Danielle Dunnett
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shreyans Gandhi
- Kings College Hospital London NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James H MacCabe
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
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Clozapine Rechallenge or Continuation Despite Neutropenia, an Extended Follow-up of a Consecutive Quebec Case Series. J Clin Psychopharmacol 2022; 42:391-395. [PMID: 35546087 DOI: 10.1097/jcp.0000000000001556] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clozapine is the most efficacious antipsychotic for treatment-resistant schizophrenia. However, clozapine-induced neutropenia may warrant treatment discontinuation, hindering recovery. Several case reports describe clozapine rechallenge or continuation despite neutropenia, although many are subject to selective reporting, with incomplete information and short follow-up periods. Thus, consecutive case series, devoid of such bias, with long-term comprehensive follow-up are needed to better assess this practice. This study aimed to describe consecutively the evolution of every patient in the Québec City catchment area for whom clozapine was either reintroduced after neutropenia during a previous clozapine trial or was maintained despite a first neutropenia. METHODS Patients were identified through clozapine's national hematological monitoring database and their medical records between January 1, 2000, and October 22, 2017. RESULTS Twenty-three patients were identified, 8 continued clozapine despite neutropenia, while 15 discontinued clozapine and attempted rechallenge; among the latter, 4 patients were successfully rechallenged after agranulocytosis without the use of granulocyte colony-stimulating factors, which is the largest published consecutively. A total of 6 patients experienced further neutropenia episodes. Every patient who had a neutropenia recurrence also had a possible explanation for neutropenia other than exposure to clozapine. After a median follow-up of 4.8 years, 16 patients were still on clozapine and 3 cases discontinued because of a hematological event. CONCLUSIONS This study adds further data on the subject of clozapine rechallenge or continuation despite neutropenia. Clozapine rechallenge after agranulocytosis may be less perilous than first thought, but a systematic review on this specific subject is needed.
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Affiliation(s)
- David Taylor
- Department of Pharmacy, Maudsley Hospital, London, UK.,Institute of Pharmaceutical Science, King's College, London, UK
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Distinctive pattern of neutrophil count change in clozapine-associated, life-threatening agranulocytosis. NPJ SCHIZOPHRENIA 2022; 8:21. [PMID: 35288577 PMCID: PMC8920060 DOI: 10.1038/s41537-022-00232-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/11/2022] [Indexed: 12/19/2022]
Abstract
The wider use of clozapine is limited by the risk of agranulocytosis and the associated requirement for monitoring of neutrophil counts. We searched local electronic patient records for cases of agranulocytosis occurring during clozapine treatment during the period 2007–2020. We found 23 episodes recorded as agranulocytosis in clozapine patients. Of these, nine met pre-defined criteria and were considered episodes of life-threatening agranulocytosis (LTA). These episodes of clozapine-induced LTA exhibited a distinct pattern of continuous and rapid neutrophil count decline to zero or near zero. Mean time for neutrophils to fall from ANC > 2 to ANC <0.5 × 109/L was 8.4 days (range 2–15 days). Each event was also characterised by a prolonged nadir and delayed recovery (range 4–16 days). Non-LTA episodes were, in contrast, brief and benign. We conclude that an important proportion of cases of agranulocytosis identified in people prescribed clozapine are not life-threatening and may not even be clozapine-related. Monitoring schemes should aim to identify true clozapine-induced LTA as opposed to threshold-defined nominal agranulocytosis. Genetics studies might benefit from examining associations with clozapine-induced LTA rather than with recorded cases of agranulocytosis or neutropenia.
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Abstract
Schizophrenia, characterised by psychotic symptoms and in many cases social and occupational decline, remains an aetiological and therapeutic challenge. Contrary to popular belief, the disorder is modestly more common in men than in women. Nor is the outcome uniformly poor. A division of symptoms into positive, negative, and disorganisation syndromes is supported by factor analysis. Catatonic symptoms are not specific to schizophrenia and so-called first rank symptoms are no longer considered diagnostically important. Cognitive impairment is now recognised as a further clinical feature of the disorder. Lateral ventricular enlargement and brain volume reductions of around 2% are established findings. Brain functional changes occur in different subregions of the frontal cortex and might ultimately be understandable in terms of disturbed interaction among large-scale brain networks. Neurochemical disturbance, involving dopamine function and glutamatergic N-methyl-D-aspartate receptor function, is supported by indirect and direct evidence. The genetic contribution to schizophrenia is now recognised to be largely polygenic. Birth and early life factors also have an important aetiological role. The mainstay of treatment remains dopamine receptor-blocking drugs; a psychological intervention, cognitive behavioural therapy, has relatively small effects on symptoms. The idea that schizophrenia is better regarded as the extreme end of a continuum of psychotic symptoms is currently influential. Other areas of debate include cannabis and childhood adversity as causative factors, whether there is progressive brain change after onset, and the long-term success of early intervention initiatives.
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Affiliation(s)
- Sameer Jauhar
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College, London, UK
| | - Mandy Johnstone
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College, London, UK; National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Peter J McKenna
- FIDMAG Hermanas Hospitalarias Research Foundation, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain.
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Oloyede E, Clark I, Mace S, Whiskey E, Taylor D. Clozapine augmentation with cariprazine for negative symptoms: a case series and literature review. Ther Adv Psychopharmacol 2022; 12:20451253211066642. [PMID: 35111297 PMCID: PMC8801710 DOI: 10.1177/20451253211066642] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/25/2021] [Indexed: 12/16/2022] Open
Abstract
Only about 50% of patients with treatment-resistant schizophrenia respond to clozapine, and many more patients continue to experience ongoing and prominent negative symptoms. These negative symptoms, for which there are limited pharmacological options, may represent the greatest barrier to functional recovery. Cariprazine is a novel antipsychotic drug that is a partial agonist at dopamine D2 and D3 receptors with preferential binding to the D3 receptor, antagonism of 5HT2B receptors, and partial agonism at 5HT1A receptors. Cariprazine is currently licenced for the treatment of schizophrenia in Europe and the United States and has also been approved for bipolar disorder in the United States. There is a limited body of evidence to suggest clinical effectiveness as an augmentation strategy for negative symptoms in those treated with clozapine. In this case series, we present five cases of successful treatment of negative symptoms by clozapine combined with cariprazine in treatment-resistant psychosis.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Ivana Clark
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Shubhra Mace
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
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Parkes S, Mantell B, Oloyede E, Blackman G. Patients' Experiences of Clozapine for Treatment-Resistant Schizophrenia: A Systematic Review. SCHIZOPHRENIA BULLETIN OPEN 2022; 3:sgac042. [PMID: 39144802 PMCID: PMC11205966 DOI: 10.1093/schizbullopen/sgac042] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Background Clozapine is the most effective antipsychotic for patients with treatment-resistant schizophrenia (TRS), however, it remains widely under-utilized in clinical practice. To date, relatively little attention has been given to patients' experience of clozapine. By synthesizing the existing literature, we sought to determine the experiences of patients with TRS treated with clozapine. Methods A systematic review was conducted on Embase, Medline, PsychInfo, and PubMed databases for studies from 1956 to 2021. English language studies and those based on adult patients prescribed clozapine for TRS were included. Results Thirteen studies were included with a total of 1487 patients and a narrative synthesis was performed. Overall, most patients reported positive experiences of clozapine, with generally high levels of satisfaction, alongside symptom improvement and preference over previous medications. Negative experiences of clozapine were less common, but when mentioned, focused on blood tests and common side effects, including hypersalivation and weight gain. Conclusions This is the first systematic review exploring patients' subjective experiences of clozapine for TRS. Findings suggest that patients generally have a favorable experience when being treated with clozapine. However, conclusions are limited by the risk of bias, particularly survivorship bias. High-quality longitudinal studies exploring patients' experiences of clozapine are indicated for the future.
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Affiliation(s)
- Steven Parkes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Bethany Mantell
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ebenezer Oloyede
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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21
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Oloyede E, Mantell B, Williams J, Lai S, Jauhar S, Taylor D, MacCabe JH, Harland R, McGuire P, Blackman G. Clozapine for treatment resistance in early psychosis: a survey of UK clinicians' training, knowledge and confidence. Ther Adv Psychopharmacol 2022; 12:20451253221141222. [PMID: 36601352 PMCID: PMC9806412 DOI: 10.1177/20451253221141222] [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: 08/23/2022] [Accepted: 11/01/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Clozapine is the only medication licenced for patients with psychosis that is resistant to conventional antipsychotic treatment. However, despite its effectiveness, it remains widely underutilised. One contributory factor for this may be clinicians' lack of confidence around the management of clozapine. OBJECTIVE We conducted a survey of clinicians working in Early Intervention in Psychosis (EIP) services to determine their training needs for clozapine management in EIP services. METHODS An electronic survey was made available to all clinicians working in EIP services in England. The survey assessed confidence and training needs regarding managing clozapine in patients with treatment-resistant psychosis. Quantitative data were analysed using total mean scores and the Mann-Whitney U test. RESULTS In all, 192 (27%) of approximately 700 clinicians from 35 EIP services completed the survey. Approximately half (54%) had not received training on treatment with clozapine. Experience of training was higher in prescribers than non-prescribers, and among medical than non-medical clinicians. Previous training was associated with significantly higher confidence in offering clozapine and managing treatment-resistant psychosis (p < 0.001). Confidence levels with managing treatment-resistant psychosis and clozapine were relatively high (mean = 4 out of 5, SD = 1). Respondents were most confident about monitoring mental health response to treatment (mean = 5, SD = 1). Participants were least confident about how to discontinue clozapine treatment safely (mean = 3, SD = 1). CONCLUSION Most clinicians working in EIP have not received training on the use of clozapine. This may account, in part, for the underutilisation of clozapine in EIP services. The provision of training in the identification of treatment-resistant psychosis and the use of clozapine will likely improve the detection and management of treatment resistance in the early phase of psychosis.
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Affiliation(s)
- Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, DeCriesney, London, UK
| | - Bethany Mantell
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Julie Williams
- Health Service and Population Research Department, Centre for Implementation Science, King's College London, London, UK
| | - Serena Lai
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Sameer Jauhar
- South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College, London
| | - James H MacCabe
- South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Robert Harland
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Philip McGuire
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, Oxfordshire, UK
| | - Graham Blackman
- South London and Maudsley NHS Foundation Trust, London, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Oloyede E, Dzahini O, Barnes N, Mijovic A, Gandhi S, Stuart-Smith S, de Witte T, Taylor D, Whiskey E. Benign ethnic neutropenia: an analysis of prevalence, timing and identification accuracy in two large inner-city NHS hospitals. BMC Psychiatry 2021; 21:502. [PMID: 34645395 PMCID: PMC8515765 DOI: 10.1186/s12888-021-03514-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benign ethnic neutropenia (BEN) is the most common cause of chronic neutropenia seen in individuals of African, Middle Eastern and West Indian descent. This phenotype is broadly defined by an absolute neutrophil counts (ANC) below 1.8 × 109 cells/L in the absence of other causes, without an increased risk of infection. BEN has been implicated as a potential source of disparity in patients treated with clozapine, the antipsychotic of choice in treatment-resistant schizophrenia. Our main objective was to examine the current level of BEN recognition in a cohort of patients treated with clozapine and the potential impact of unidentified BEN on the initiation and maintenance of clozapine treatment. METHODS This was an observational, retrospective analysis of patients registered with clozapine haematological monitoring systems in two large mental health trusts, chosen because they serve an ethnically diverse population. The first objective was to establish certified BEN prevalence in current users of clozapine. The second objective was to explore the stage of treatment at which BEN was identified. The third objective was to evaluate the extent of unrecognised BEN in patients registered on the Central Non-Rechallenge Database (CNRD), a database for patients whose haematological parameters fall below set thresholds when receiving clozapine treatment, meaning they cannot ordinarily be prescribed clozapine again. RESULTS The study population comprised of 2020 patients on the clozapine register. 111 patients were monitored under BEN criteria. BEN was mostly identified after a below threshold haematological result or clozapine rechallenge (68%) compared to at clozapine initiation (32%). Eight of the 18 (42%) black patients registered on the CNRD were classified as BEN after assessment by a haematologist. Of these 8 patients, none would have met CNRD criteria again if monitored with BEN criteria at clozapine initiation. CONCLUSIONS Current evidence suggests that BEN remains an uncommonly recognised haematological phenotype. Improved timely identification of BEN will reduce unnecessary interruption or discontinuation of clozapine treatment. Our results suggest consideration should also be given to determining BEN status prior to initiating clozapine. Moreover, adoption of current FDA BEN monitoring criteria in the UK may further reduce clozapine discontinuation due to perceived neutropenia as drug toxicity, particularly in treatment-refractory schizophrenia patients.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK. .,King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.
| | - Olubanke Dzahini
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
| | - Nigel Barnes
- grid.450453.3Pharmacy Department, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Aleksandar Mijovic
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Shreyans Gandhi
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Sara Stuart-Smith
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Theo de Witte
- grid.5590.90000000122931605Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, Netherlands
| | - David Taylor
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
| | - Eromona Whiskey
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
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