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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [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: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Metro South Community and Oral Health, Department of Pharmacy, Brisbane, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Jeong SH, Lee MG, Kim YS, Chung IW. Change in absolute neutrophil count after COVID-19 infection in patients using clozapine versus other antipsychotics. Int Clin Psychopharmacol 2024; 39:187-194. [PMID: 38261424 DOI: 10.1097/yic.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
It was reported that patients who contracted COVID-19 while taking clozapine exhibited a distinct hematological response. However, the absence of control groups made it difficult to attribute it to clozapine. The changes in absolute neutrophil counts (ANCs) during the 4 weeks after COVID-19 infection were compared between the two groups of patients with severe mental illnesses (SMIs) (49 patients using clozapine and 54 using other antipsychotics) using generalized additive modeling. Although the pattern of a transient drop in ANC followed by gradual recovery could be demonstrated in both groups, it was more pronounced in the clozapine group ( P = 0.00025). Nevertheless, overall ANC remained at a higher level in the clozapine group. The results suggested potential interaction between clozapine and COVID-19 at the level of hematological dynamics. However, it did not necessarily indicate that such interaction is inevitably harmful or dangerous. It was more of a concern that some patients using other antipsychotics exhibited decreased ANC, which did not easily recover. Traditionally, clinicians have been concerned about the worsening of hematological side effects in clozapine patients after COVID-19 infection. However, the obtained result highlighted the necessity of hematological monitoring in patients using any type of antipsychotics for SMIs.
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Affiliation(s)
- Seong Hoon Jeong
- Department of Psychiatry, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon
| | | | - Yong Sik Kim
- Department of Psychiatry, Nowon-Uiijeongbu Eulji Medical Center, Eulji University School of Medicine, Seoul
- Institute of Clinical Psychopharmacology, Dongguk University School of Medicine, Goyang
| | - In Won Chung
- Department of Psychiatry and Yong-In Psychiatric Institute, Yong-In Mental Hospital, Yongin, Republic of Korea
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Lin Y, Yang Y, Xiang N, Wang L, Zheng T, Zhuo X, Shi R, Su X, Liu Y, Liao G, Du L, Huang J. Characterization and trajectories of hematological parameters prior to severe COVID-19 based on a large-scale prospective health checkup cohort in western China: a longitudinal study of 13-year follow-up. BMC Med 2024; 22:105. [PMID: 38454462 PMCID: PMC10921814 DOI: 10.1186/s12916-024-03326-x] [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: 03/12/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The relaxation of the "zero-COVID" policy on Dec. 7, 2022, in China posed a major public health threat recently. Complete blood count test was discovered to have complicated relationships with COVID-19 after the infection, while very few studies could track long-term monitoring of the health status and identify the characterization of hematological parameters prior to COVID-19. METHODS Based on a 13-year longitudinal prospective health checkup cohort of ~ 480,000 participants in West China Hospital, the largest medical center in western China, we documented 998 participants with a laboratory-confirmed diagnosis of COVID-19 during the 1 month after the policy. We performed a time-to-event analysis to explore the associations of severe COVID-19 patients diagnosed, with 34 different hematological parameters at the baseline level prior to COVID-19, including the whole and the subtypes of white and red blood cells. RESULTS A total of 998 participants with a positive SARS-CoV-2 test were documented in the cohort, 42 of which were severe cases. For white blood cell-related parameters, a higher level of basophil percentage (HR = 6.164, 95% CI = 2.066-18.393, P = 0.001) and monocyte percentage (HR = 1.283, 95% CI = 1.046-1.573, P = 0.017) were found associated with the severe COVID-19. For lymphocyte-related parameters, a lower level of lymphocyte count (HR = 0.571, 95% CI = 0.341-0.955, P = 0.033), and a higher CD4/CD8 ratio (HR = 2.473, 95% CI = 1.009-6.059, P = 0.048) were found related to the risk of severe COVID-19. We also observed that abnormality of red cell distribution width (RDW), mean corpuscular hemoglobin concentration (MCHC), and hemoglobin might also be involved in the development of severe COVID-19. The different trajectory patterns of RDW-SD and white blood cell count, including lymphocyte and neutrophil, prior to the infection were also discovered to have significant associations with the risk of severe COVID-19 (all P < 0.05). CONCLUSIONS Our findings might help decision-makers and clinicians to classify different risk groups of population due to outbreaks including COVID-19. They could not only optimize the allocation of medical resources, but also help them be more proactive instead of reactive to long COVID-19 or even other outbreaks in the future.
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Affiliation(s)
- Yifei Lin
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yong Yang
- Health Management Center, General Practice Medical Center, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Nanyan Xiang
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Le Wang
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, Frontiers Science Center for Disease-Related Molecular Network, Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Sciences, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Tao Zheng
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xuejun Zhuo
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Rui Shi
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xiaoyi Su
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, Chinese Evidence-Based Medicine Center, West China Hospital, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yan Liu
- Department of Neurosurgery, Innovation Institute for Integration of Medicine and Engineering, Ministry of Education, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Ga Liao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Liang Du
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Jin Huang
- Department of Urology, Innovation Institute for Integration of Medicine and Engineering, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Jones R, Morales-Munoz I, Shields A, Blackman G, Legge SE, Pritchard M, Kornblum D, MacCabe JH, Upthegrove R. Early neutrophil trajectory following clozapine may predict clozapine response - Results from an observational study using electronic health records. Brain Behav Immun 2023; 113:267-274. [PMID: 37494985 DOI: 10.1016/j.bbi.2023.07.012] [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: 05/02/2023] [Revised: 07/11/2023] [Accepted: 07/22/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Clozapine has unique effectiveness in treatment-resistant schizophrenia and is known to cause immunological side-effects. A transient spike in neutrophils commonly occurs in the first weeks of clozapine therapy. There is contradictory evidence in the literature as to whether neutrophil changes with clozapine are linked to treatment response. AIMS The current study aims to further examine the neutrophil changes in response to clozapine and explore any association between neutrophil trajectory and treatment response. METHODS A retrospective cohort study of patients undergoing their first treatment with clozapine and continuing for at least 2 years identified 425 patients (69% male/31% female). Neutrophil counts at baseline, 3 weeks and 1 month were obtained predominantly by linkage with data from the clozapine monitoring service. Clinical Global Impression- Severity (CGI-S) was rated from case notes at the time of clozapine initiation and at 2 years. Latent class growth analysis (LCGA) was performed to define distinct trajectories of neutrophil changes during the first month of treatment. Logistic regression was then conducted to investigate for association between the trajectory of neutrophil count changes in month 1 and clinical response at 2 years as well as between baseline neutrophil count and response. RESULTS Of the original cohort, 397 (93%) patients had useable neutrophil data during the first 6 weeks of clozapine treatment. LCGA revealed significant differences in neutrophil trajectories with a three-class model being the most parsimonious. The classes had similar trajectory profiles but differed primarily on overall neutrophil count: with low, high-normal and high neutrophil classes, comprising 52%, 40% and 8% of the sample respectively. Membership of the high-normal group was associated with significantly increased odds of a positive response to clozapine, as compared to the low neutrophil group [Odds ratio (OR) = 2.10, p-value = 0.002; 95% confidence interval (95% CI) = 1.31-3.36]. Baseline neutrophil count was a predictor of response to clozapine at 2 years, with counts of ≥5 × 109/l significantly associated with positive response (OR = 1.60, p-value = 0.03; 95% CI = 1.03-2.49). CONCLUSIONS Our data are consistent with the hypothesis that patients with low-level inflammation, reflected in a high-normal neutrophil count, are more likely to respond to clozapine, raising the possibility that clozapine exerts its superior efficacy via immune mechanisms.
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Affiliation(s)
- Rowena Jones
- Institute for Mental Health, School of Psychology, University of Birmingham, UK; Birmingham and Solihull Mental Health Foundation Trust, UK.
| | | | - Adrian Shields
- Clinical Immunology Service, University of Birmingham, UK
| | - Graham Blackman
- Department of Psychiatry, University of Oxford, Warneford Hospital, OX3 7JX, UK; Department of Psychosis Studies, King's College London, and South London and Maudsley NHS Foundation Trust, UK
| | - Sophie E Legge
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Daisy Kornblum
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, UK
| | - James H MacCabe
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, UK; Department of Psychosis Studies, King's College London, and South London and Maudsley NHS Foundation Trust, UK
| | - Rachel Upthegrove
- Institute for Mental Health, School of Psychology, University of Birmingham, UK; Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK
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Huang L, Xu J, Zhang H, Wang M, Zhang Y, Lin Q. Application and investigation of thrombopoiesis-stimulating agents in the treatment of thrombocytopenia. Ther Adv Hematol 2023; 14:20406207231152746. [PMID: 36865986 PMCID: PMC9972067 DOI: 10.1177/20406207231152746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/06/2023] [Indexed: 03/02/2023] Open
Abstract
Platelets, derived from a certain subpopulation of megakaryocytes, are closely related to hemostasis, coagulation, metastasis, inflammation, and cancer progression. Thrombopoiesis is a dynamic process regulated by various signaling pathways in which thrombopoietin (THPO)-MPL is dominant. Thrombopoiesis-stimulating agents could promote platelet production, showing therapeutic effects in different kinds of thrombocytopenia. Some thrombopoiesis-stimulating agents are currently used in clinical practices to treat thrombocytopenia. The others are not in clinical investigations to deal with thrombocytopenia but have potential in thrombopoiesis. Their potential values in thrombocytopenia treatment should be highly regarded. Novel drug screening models and drug repurposing research have found many new agents and yielded promising outcomes in preclinical or clinical studies. This review will briefly introduce thrombopoiesis-stimulating agents currently or potentially valuable in thrombocytopenia treatment and summarize the possible mechanisms and therapeutic effects, which may enrich the pharmacological armamentarium for the medical treatment of thrombocytopenia.
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Affiliation(s)
- Lejun Huang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Jianxuan Xu
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Huaying Zhang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Mengfan Wang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Yiyue Zhang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
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Wafaa H, Magadmi R, Hakami N, Al Sadoun H, Almaghrabi S, Mohammed N, Alrafiah A. Is Vitamin B12 Level a Reliable Predictor of Psychosis Severity in Male Patients with Megaloblastic Anemia at a Single Tertiary Hospital? Int J Gen Med 2022; 15:7657-7668. [PMID: 36217368 PMCID: PMC9547595 DOI: 10.2147/ijgm.s384432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background Megaloblastic anemia (MA) occurs due to ineffective erythropoiesis, which results from impaired DNA synthesis in the hematopoietic precursors and intramedullary hemolysis. MA’s most common cause is nutritional deficiencies of either cobalamin (vitamin B12) or folate (vitamin B6). This study aims to determine the association between MA caused by vitamin B12 deficiency and psychosis among psychotic male patients in Mental Health Hospital at Taif, Saudi Arabia. Methods Fifty psychotic male patients, aged 48.58±1.72, were recruited from the Mental Health Hospital at Taif, Saudi Arabia, in addition to 54 sex-matched healthy controls. The following tests were run: complete blood count (CBC), liver function tests (LFT), serum levels of vitamin B12, folate, and C-reactive protein (CRP). Results The CBC showed that RBCs count, haemoglobin, haematocrit, platelets count, mean platelets volume (MPV), and absolute lymphocyte count were significantly lower in psychotic patients versus healthy controls (P=0.007, P=0.002, P=0.001, P=0.004, P=0.0001, and P=0.005, respectively). In contrast, the eosinophil absolute count and basophil percentage were significantly higher in psychotic patients versus controls (P=0.009, P=0.0001, respectively). Vitamin B12 levels were insignificantly decreased in psychotic patients versus healthy group. There were significant negative correlations between serum levels of VitB12 and negative symptoms (r=−0.381, P=0.006) and hallucination (r=−0.297, P=0.036). Conclusion These findings indicate no link between MA induced by VitB12 insufficiency and psychosis among psychotic patients. However, low serum VitB12 can predict the severity of some psychosis signs, including hallucinations and negative symptoms. Therefore, monitoring VitB12 levels and its supplementation in psychotic patients is recommended to improve their symptoms.
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Affiliation(s)
- Hanaa Wafaa
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rania Magadmi
- Pharmacology Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nora Hakami
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hadeel Al Sadoun
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Safa Almaghrabi
- Department of Physiology, Medical School, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nuha Mohammed
- Department of Medical Laboratory, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Aziza Alrafiah
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Science, King Abdulaziz University, Jeddah, Saudi Arabia,Correspondence: Aziza Alrafiah, P.O Box 80200, Jeddah, 21589, Saudi Arabia, Tel +966 0126401000 Ext. 23495, Fax +966 0126401000 Ext. 21686, Email
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Al Abadey A, Connor B, Flamme ACL, Robichon K. Clozapine reduces chemokine-mediated migration of lymphocytes by targeting NF-κB and AKT phosphorylation. Cell Signal 2022; 99:110449. [PMID: 36031090 DOI: 10.1016/j.cellsig.2022.110449] [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: 06/20/2022] [Revised: 08/11/2022] [Accepted: 08/22/2022] [Indexed: 11/27/2022]
Abstract
Multiple sclerosis is a disease characterised by demyelination of axons in the central nervous system. The atypical antipsychotic drug clozapine has been shown to attenuate disease severity in experimental autoimmune encephalomyelitis (EAE), a mouse model that is useful for the study of multiple sclerosis. However, the mechanism of action by which clozapine reduces disease in EAE is poorly understood. To better understand how clozapine exerts its protective effects, we investigated the underlying signalling pathways by which clozapine may reduce immune cell migration by evaluating chemokine and dopamine receptor-associated signalling pathways. We found that clozapine inhibits migration of immune cells by reducing chemokine production in microglia cells by targeting NF-κB phosphorylation and promoting an anti-inflammatory milieu. Furthermore, clozapine directly targets immune cell migration by changing Ca2+ levels within immune cells and reduces the phosphorylation of signalling protein AKT. Linking these pathways to the antagonising effect of clozapine on dopamine and serotonin receptors, we provide insight into how clozapine alters immune cells migration by directly targeting the underlying migration-associated pathways.
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Affiliation(s)
- Afnan Al Abadey
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Centre for Biodiscovery Wellington, Victoria University of Wellington, Wellington, New Zealand
| | - Bronwen Connor
- Department of Pharmacology and Clinical Pharmacology, Centre for Brain Research, University of Auckland, Auckland, New Zealand
| | - Anne Camille La Flamme
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Centre for Biodiscovery Wellington, Victoria University of Wellington, Wellington, New Zealand; Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Katharina Robichon
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Centre for Biodiscovery Wellington, Victoria University of Wellington, Wellington, New Zealand.
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Emmanoella Sebulsqui Saraiva T, Rodrigues GZP, Kayser JM, Dallegrave E, Pulz Maus N, Veiverberg A, da Costa Berna G, Schuster AC, Gabriela de Freitas M, Galdino da Rocha Pitta M, da Rocha Pitta I, Gehlen G, Betti AH. Study of the acute and repeated dose 28-day oral toxicity in mice treated with PT-31, a molecule with potential antipsychotic profile. Toxicol Mech Methods 2022; 32:705-715. [PMID: 35410575 DOI: 10.1080/15376516.2022.2065226] [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: 10/18/2022]
Abstract
Schizophrenia is a psychiatric disorder that affects 1% of the world population and is treated with antipsychotics, which may induce important biochemical and hematological alterations. Since it is necessary to verify the safety of new molecules with antipsychotic potential, the present study aimed to evaluate the oral toxicity of PT-31, a putative α2-adrenoreceptor agonist, after acute (2000 mg/kg) and repeated doses (28 days) gavage treatment, in three different doses: minimum effective dose in animal models (10 mg/kg), twice the dose (20 mg/kg), and four times the dose (40 mg/kg), as recommended by the OECD guidelines. Balb/C female adult mice were used, and biochemical, hematological, and histopathological analyses were performed. PT-31 10 and 20 mg/kg did not cause biochemical alterations related to hepatic and renal toxicity, and neither altered glycemic and lipid profiles. The preclinical dose of PT-31 also did not promote mice histopathological changes in the liver, kidney, and brain. In the hematimetric parameters, PT-31 only increased HGB at 20 mg/kg, and MCH and MCHC at 40 mg/kg. However, all the tested doses of PT-31 showed platelet increase, which must be better investigated. Therefore, further studies are needed to investigate the safety of PT-31 as a potential antipsychotic drug.
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Affiliation(s)
| | | | - Juliana Machado Kayser
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
| | - Eliane Dallegrave
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Nathália Pulz Maus
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
| | - Andriele Veiverberg
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
| | - Gabriel da Costa Berna
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
| | | | | | | | - Ivan da Rocha Pitta
- Research Centre for Therapeutic Innovation. Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Günther Gehlen
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
| | - Andresa Heemann Betti
- Institute of Health Sciences, Feevale University, Novo Hamburgo, Rio Grande do Sul, Brazil
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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: 6] [Impact Index Per Article: 3.0] [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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Johannsen CF, Petersen TS, Nielsen J, Jørgensen A, Jimenez-Solem E, Fink-Jensen A. Clozapine- and non-clozapine-associated neutropenia in patients with schizophrenia: a retrospective cohort study. Ther Adv Psychopharmacol 2022; 12:20451253211072341. [PMID: 35273789 PMCID: PMC8902187 DOI: 10.1177/20451253211072341] [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: 09/14/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The antipsychotic drug clozapine remains underutilized partly because of the risk of life-threatening adverse effects, such as neutropenia. Therefore, an extensive hematological monitoring program was set up to detect neutropenia. METHODS In this retrospective cohort study, we used registry-based data from the Capital Region of Denmark to investigate incidence rates of neutropenia among patients with a diagnosis of schizophrenia or other psychotic disorders and treated with clozapine for the first time. In a within-subject design, we compared rates of neutropenia in time periods where patients were exposed to clozapine versus time periods, where they were not exposed to clozapine. We also investigated whether the lengths of clozapine-associated neutropenia (CAN) were related to discontinuation of clozapine treatment. RESULTS Data from 520 clozapine users were included. The incidence rate of CAN was 3.2 cases per 100 person-years (95% confidence interval [CI]: 2.1-4.8) throughout the entire study. There was no significant difference in incidence rates of neutropenia during clozapine exposure and non-clozapine exposure, with an incidence rate ratio of 0.7 (95% CI: 0.4-1.3). One episode of severe neutropenia was detected. Episodes of CAN with only one sub-threshold neutrophil count were not associated with higher clozapine discontinuation (26%) than CAN episodes of more than one sub-threshold neutrophil count (28%). CONCLUSION In the present study, we could not confirm that clozapine treatment was associated with neutropenia.
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Affiliation(s)
- Claas-Frederik Johannsen
- Mental Health Centre Copenhagen, Rigshospitalet, Edel Sauntes Allé 10, 2100 Copenhagen Ø, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, DenmarkDepartment of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
| | - Jimmi Nielsen
- Mental Health Centre Glostrup, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
| | - Anders Jørgensen
- Mental Health Centre Copenhagen, Rigshospitalet, Copenhagen Ø, DenmarkDepartment of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology and Copenhagen Phase 4 Unit, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, DenmarkDepartment of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
| | - Anders Fink-Jensen
- Mental Health Centre Copenhagen, Rigshospitalet, Edel Sauntes Allé 10, 2100 Copenhagen Ø, DenmarkDepartment of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
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Blackman G, Lisshammar JE, Zafar R, Pollak TA, Pritchard M, Cullen AE, Rogers J, Carter B, Griffiths K, Nour M, David AS, McGuire P, Stewart R, MacCabe J. Clozapine Response in Schizophrenia and Hematological Changes. J Clin Psychopharmacol 2021; 41:19-24. [PMID: 33347018 PMCID: PMC7752217 DOI: 10.1097/jcp.0000000000001329] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clozapine is the only effective medication for treatment-resistant schizophrenia; however, its mechanism of action remains unclear. The present study explored whether its effectiveness is related to changes in hematological measures after clozapine initiation. METHODS Patients with treatment-resistant schizophrenia commenced on clozapine between January 2007 and December 2014 by the United Kingdom's largest mental health trust were identified from electronic patient records. Hematological data from these patients were obtained from a monitoring registry. White blood cell, neutrophil, and platelet count were assessed at baseline and during the early phase of clozapine treatment. Clozapine response at 3 months was defined as "much," or "very much" improved on the seven-point Clinical Global Impression-Improvement (CGI-I) subscale. RESULTS In the total sample (n = 188), clozapine initiation was associated with a significant transient increase (peaking in weeks 3 to 4) in white blood cell, neutrophil, and platelet count (P < 0.001). There were 112 (59.6%) patients that responded to treatment; however, none of the hematological factors assessed at baseline, nor changes in these factors, were directly associated with treatment response. IMPLICATIONS Clozapine treatment is associated with transient hematological changes during the first month of treatment; however, there was no evidence that these were related to the therapeutic response.
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Affiliation(s)
- Graham Blackman
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- South London and Maudsley NHS Foundation Trust
| | - Jenny E.L. Lisshammar
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- Central North West London NHS Foundation Trust
| | - Rayyan Zafar
- Centre for Neuropsychopharmacology, Imperial College London Trust
| | - Thomas A. Pollak
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- South London and Maudsley NHS Foundation Trust
| | - Megan Pritchard
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London
| | - Alexis E. Cullen
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
| | - Jonathan Rogers
- South London and Maudsley NHS Foundation Trust
- Division of Psychiatry, University College London
| | - Ben Carter
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London
| | - Kira Griffiths
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
| | - Matthew Nour
- South London and Maudsley NHS Foundation Trust
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research
| | - Anthony S. David
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- UCL Institute of Mental Health, University College London, London, United Kingdom
| | - Philip McGuire
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- South London and Maudsley NHS Foundation Trust
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London
| | - James MacCabe
- From the Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London
- South London and Maudsley NHS Foundation Trust
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Leukocytosis Associated with Clozapine Treatment: A Case Series and Systematic Review of the Literature. ACTA ACUST UNITED AC 2021; 57:medicina57080816. [PMID: 34441022 PMCID: PMC8399375 DOI: 10.3390/medicina57080816] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia. Despite its superior efficacy profile as compared with other antipsychotics, clozapine remains underutilized. Clozapine monitoring systems clearly describe the proposed management of clozapine-induced neutropenia; however, no specific mention is made of how to interpret neutrophilic leukocytosis, despite that being a relatively frequent finding. Prescribers unfamiliar with this molecule may misjudge its clinical significance, potentially leading to untimely treatment interruption. Here, we systematically review the literature on the risk of neutrophilic leukocytosis during clozapine treatment, and describe eight additional cases among our patient cohort. MATERIALS AND METHODS We performed a systematic review of the literature on PubMed and Embase using the PRISMA 2020 guidelines, and selected all original reports describing either (1) the prevalence of neutrophilic leukocytosis during clozapine treatment, or (2) the clinical significance of neutrophilic leukocytosis. We described eight additional cases of neutrophilic leukocytosis during clozapine treatment while attending an outpatient psychiatric clinic. RESULTS Our research ultimately yielded the selection of 13 articles included in this systematic review. The case series highlighted the presence of stable and clinically unremarkable neutrophilia during a follow-up ranging from one to ten years. CONCLUSIONS Existing evidence indicates that leukocytosis associated with clozapine treatment can be considered as an asymptomatic and benign condition, suggesting that no change in clozapine treatment is needed upon its detection.
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13
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de Filippis R, Gaetano R, Schoretsanitis G, Verde G, Oliveti CA, Kane JM, Segura-Garcia C, De Fazio P. Clozapine Management in Schizophrenia Inpatients: A 5-Year Prospective Observational Study of Its Safety and Tolerability Profile. Neuropsychiatr Dis Treat 2021; 17:2141-2150. [PMID: 34234440 PMCID: PMC8257059 DOI: 10.2147/ndt.s312095] [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: 03/24/2021] [Accepted: 06/15/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Clozapine is well known for its efficacy and clinical superiority compared to other antipsychotics in treatment-resistant schizophrenia (TRS). However, it is frequently underutilized worldwide because of its acute adverse events, as well as for its long-term cardiometabolic and hematological consequences. OBJECTIVE The aim of the study was to evaluate 5-year safety in chronic TRS inpatients with continuous clozapine use. METHODS Patients with TRS and clozapine treatment were evaluated for 5 years. All participants were assessed using the Brief Psychiatric Rating Scale (BPRS), Glasgow Antipsychotic Side-effect Scale for Clozapine (GASS-C), Social Performance Scale (PSP) and Short Portable Mental Status Questionnaire (SPMSQ). Clinical, cardiometabolic and hematological data were collected periodically. General linear models (GLM) repeated measures controlling for CLZ dose were utilized to determine differences in variables across the time. RESULTS Overall, 189 inpatients were screened for study participation. The final sample included twenty-one TRS patients (16 males, 76%) with an average age of 57.6 years, all with 5-year continuous use of clozapine (mean dose 266 mg/day). There was not a significant effect of time on BPRS (p=0.774), PSP (p=0.855) and SPMSQ (p=0.066); differences remained not significant after controlling for CLZ dose (p=0.585, p=0.467 and p=0.105, respectively). No changes were found in blood and clinical parameters except for red blood cell count, which decreased over time (p=0.024; η2= 0.952). Patients reported a significant BMI decrease (-8.98 kg, p=0.008) between baseline and 5 years last observation. CONCLUSION The findings show how the application of a structured dietary, clinical and therapeutic monitoring program in psychiatric care facilities could allow the safe and effective long-term cardiometabolic and hematological management of clozapine. The unique role that clozapine plays in the current treatment of patients with TRS requires greater clinical awareness. Although its acute and chronic side effects are notorious, its safety management is feasible and broadens its potential practical application.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Gaetano
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Giuseppe Verde
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Cristina Segura-Garcia
- Psychiatry Unit, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Sershen H, Guidotti A, Auta J, Drnevich J, Grayson DR, Veldic M, Meyers J, Youseff M, Zhubi A, Faurot K, Wu R, Zhao J, Jin H, Lajtha A, Davis JM, Smith RC. Gene Expression Of Methylation Cycle And Related Genes In Lymphocytes And Brain Of Patients With Schizophrenia And Non-Psychotic Controls. Biomark Neuropsychiatry 2021; 5. [PMID: 34368786 DOI: 10.1016/j.bionps.2021.100038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Some of the biochemical abnormalities underlying schizophrenia, involve differences in methylation and methylating enzymes, as well as other related target genes. We present results of a study of differences in mRNA expression in peripheral blood lymphocytes (PBLs) and post-mortem brains of chronic schizophrenics (CSZ) and non-psychotic controls (NPC), emphasizing the differential effects of sex and antipsychotic drug treatment on mRNA findings. We studied mRNA expression in lymphocytes of 61 CSZ and 49 NPC subjects using qPCR assays with TaqMan probes to assess levels of DNMT, TET, GABAergic, NR3C1, BDNF mRNAs, and several additional targets identified in a recent RNA sequence analysis. In parallel we studied DNMT1 and GAD67 in samples of brain tissues from 19 CSZ, 26 NPC. In PBLs DNMT1 and DNMT3A mRNA levels were significantly higher in male CSZ vs NPC. No significant differences were detected in females. The GAD1, NR3C1 and CNTNAP2 mRNA levels were significantly higher in CSZ than NPC. In CSZ patients treated with clozapine, GAD-1 related, CNTNAP2, and IMPA2 mRNAs were significantly higher than in CSZ subjects not treated with clozapine. Differences between CSZ vs NPC in these mRNAs was primarily attributable to the clozapine treatment. In the brain samples, DNMT1 was significantly higher and GAD67 was significantly lower in CSZ than in NPC, but there were no significant sex differences in diagnostic effects. These findings highlight the importance of considering sex and drug treatment effects in assessing the substantive significance of differences in mRNAs between CSZ and NPC.
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Affiliation(s)
- Henry Sershen
- Nathan Kline Institute for Psychiatric Research, Orangeburg, New York, USA.,NYU Langone Medical Center, Department of Psychiatry, New York, New York, USA
| | - Alessandro Guidotti
- Psychiatric Institute University of Illinois, Department of Psychiatry, Chicago, Illinois, USA
| | - James Auta
- Psychiatric Institute University of Illinois, Department of Psychiatry, Chicago, Illinois, USA
| | - Jenny Drnevich
- High Performance Biological Computing group and the Roy J. Carver Biotechnology Center University of Illinois, Urbana, USA
| | - Dennis R Grayson
- Psychiatric Institute University of Illinois, Department of Psychiatry, Chicago, Illinois, USA
| | - Marin Veldic
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jordan Meyers
- Oregon Health and Science University, Portland, Oregon, USA
| | - Mary Youseff
- Harlem Hospital, Department of Psychiatry, New York, NY, US
| | - Adrian Zhubi
- Psychiatric Institute University of Illinois, Department of Psychiatry, Chicago, Illinois, USA
| | - Keturah Faurot
- Department of Physical Medicine & Rehabilitation, University of North Carolina at Chapel Hill, North Carolina
| | - Renrong Wu
- Department of Psychiatry, the Second Xiangya Hospital, Central South University, Changsha, Hunan, and Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jingping Zhao
- Department of Psychiatry, the Second Xiangya Hospital, Central South University, Changsha, Hunan, and Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hua Jin
- University of California San Diego, Department of Psychiatry, San Diego, and VA San Diego Healthcare System, San Diego, California, USA
| | - Abel Lajtha
- Nathan Kline Institute for Psychiatric Research, Orangeburg, New York, USA.,NYU Langone Medical Center, Department of Psychiatry, New York, New York, USA
| | - John M Davis
- Psychiatric Institute University of Illinois, Department of Psychiatry, Chicago, Illinois, USA
| | - Robert C Smith
- Nathan Kline Institute for Psychiatric Research, Orangeburg, New York, USA.,NYU Langone Medical Center, Department of Psychiatry, New York, New York, USA
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15
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Tsamakis K, Mueller C, Hortis I, Kallergi M, Tolos I, Alevyzakis E, Siafakas N, Ouranidis A, Tsiptsios D, Kympouropoulos S, Spandidos DA, Smyrnis N, Rizos E. Association of antipsychotic use with raised eosinophil count. Exp Ther Med 2021; 21:513. [PMID: 33791022 PMCID: PMC8005733 DOI: 10.3892/etm.2021.9944] [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: 11/12/2020] [Accepted: 01/26/2021] [Indexed: 01/20/2023] Open
Abstract
The current study aimed to assess the possibility of an association between first and second generation antipsychotic medication and raised eosinophil count. A total of 22 in-patients at the psychiatric unit of the University General Hospital ‘Attikon’, a tertiary hospital, were included in the present study. Patients had received antipsychotic monotherapy and did not have any co-morbidities or require additional treatments. Patients were monitored weekly and their eosinophil count was assessed. One-way ANOVA and summary measures analysis were applied to study the effect of time and medication type on the absolute eosinophil concentration (or relative percentage) for each patient. The differences in mean eosinophil concentrations or relative percentage by patient and time were also assessed. An increase in the absolute concentration and the relative percentage of eosinophils over time was observed in patients receiving Olanzapine, Haloperidol and Aripiprazole. However, there was no difference between individual medications. In conclusion, antipsychotics may be associated with increased eosinophil count over time; however, larger studies involving more patients and a longer follow-up are required to reach a definitive conclusion.
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Affiliation(s)
- Konstantinos Tsamakis
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Christoph Mueller
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.,South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Ioannis Hortis
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Maria Kallergi
- Department of Biomedical Engineering, University of West Attica, Campus I, Athens 12243, Greece
| | - Ioannis Tolos
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Evangelos Alevyzakis
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Nikolaos Siafakas
- Second Laboratory of Microbiology, University General Hospital 'ATTIKON', National and Kapodistrian University of Athens, Medical School, Athens 12462, Greece
| | - Andreas Ouranidis
- Department of Pharmaceutical Technology, School of Pharmacy, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Dimitrios Tsiptsios
- Department of Neurophysiology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR47TP, UK
| | - Stylianos Kympouropoulos
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, Heraklion 71003, Greece
| | - Nikolaos Smyrnis
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Emmanouil Rizos
- Second Department of Psychiatry, University General Hospital 'Attikon', National and Kapodistrian University of Athens, Athens 12462, Greece
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Does the Starting of Clozapine Influence Coprescription of Other Medications?: A Study From India. J Clin Psychopharmacol 2021; 41:148-154. [PMID: 33666401 DOI: 10.1097/jcp.0000000000001348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE/BACKGROUND Little is understood about the prescription load before and after the starting of clozapine. Accordingly, this study aimed to evaluate the medication load of patients receiving clozapine, just before starting clozapine and after being on clozapine for at least 1 year. Additionally, the impact of clozapine on severity of illness was evaluated. METHODS/PROCEDURES Two hundred seventy-seven outpatients receiving clozapine were prospectively evaluated for their prescription after at least 1 year of starting clozapine. Additionally, these patients were assessed on the Clinical Global Impression-Improvement scale to evaluate the overall clinical benefit with clozapine. FINDINGS/RESULTS They had been receiving clozapine for 6.55 (SD, 4.8; range, 1-24; median, 5) years at the time of assessment. At the start of clozapine, more than one third of the patients were receiving 2 antipsychotics. A small proportion was receiving other psychotropics, such as antidepressants, mood stabilizers, and benzodiazepines. After being on clozapine for 1 year, there was a significant reduction in the number of patients receiving two antipsychotic medications (P < 0.001), number of patients receiving antidepressants (if amitriptyline was left out), benzodiazepine (P < 0.001), and anticholinergic medications (P < 0.001). Further, there was a reduction in the mean chlorpromazine equivalent of antipsychotics (P < 0.001) and the total number of medications received by the patients (P < 0.001). However, there was an increase in the prescription rates of antihypertensive drugs (P = 0.03), anti-diabetic medications (P < 0.01), and anti-dyslipidemic medications. At follow-up, there was a significant improvement in symptoms as assessed by Clinical Global Impression-Improvement scale. IMPLICATIONS/CONCLUSIONS This study suggests that long-term use of clozapine is associated with substantial improvement in symptoms with a reduction in the medication load.
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17
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Patel RA, Hall DA, Eichenseer S, Bailey M. Movement Disorders and Hematologic Diseases. Mov Disord Clin Pract 2021; 8:193-207. [PMID: 33553488 DOI: 10.1002/mdc3.13129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/27/2020] [Accepted: 11/13/2020] [Indexed: 11/11/2022] Open
Abstract
Background Movement disorders can be associated with or caused by hematological abnormalities. The objective of this review is to highlight features that will aid in the clinician's recognition and treatment of these disorders. Methods MESH terms relevant to movement disorders and hematologic diseases were searched to identify conditions included in this narrative, educational review. Results Several conditions were identified, and they were organized by hematologic categories to include red blood cell abnormalities, white blood cell abnormalities, disorders of clotting and bleeding, hematologic malignancies, and others. Conclusions This review will increase providers' understanding of disorders that include movement disorders and hematologic abnormalities. Basic hematologic laboratories can aid in assessment of these disorders, to include complete blood count/hemogram and peripheral blood smear. Recognition is key, especially in the setting of underlying malignancy, vitamin deficiency, or other disorder in which treatment is available.
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Affiliation(s)
- Roshni Abee Patel
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | - Deborah A Hall
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | - Sheila Eichenseer
- Department of Neurology Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Meagan Bailey
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
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18
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Hauseux PA, Abdel Ahad P, Leroy S, de Revel T, Gaillard R. Clozapine rechallenge after thrombocytopenia: A case report. Schizophr Res 2020; 222:477-479. [PMID: 32571620 DOI: 10.1016/j.schres.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Pierre-Alain Hauseux
- Pôle hospitalo-universitaire de psychiatrie adulte Paris 15(ème), GHU Paris psychiatrie et neurosciences, site Sainte-Anne, Paris, France.
| | - Pierre Abdel Ahad
- Pôle hospitalo-universitaire de psychiatrie adulte Paris 15(ème), GHU Paris psychiatrie et neurosciences, site Sainte-Anne, Paris, France
| | - Sylvain Leroy
- Pôle de pharmacie, GHU Paris psychiatrie et neurosciences, site Sainte-Anne, Paris, France
| | - Thierry de Revel
- Service d'hématologie, Hôpital Américain de Paris, Neuilly-sur-Seine, France
| | - Raphaël Gaillard
- Pôle hospitalo-universitaire de psychiatrie adulte Paris 15(ème), GHU Paris psychiatrie et neurosciences, site Sainte-Anne, Paris, France; Université de Paris, Paris, France
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19
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Haematological side effects associated with clozapine: A retrospective study from India. Asian J Psychiatr 2020; 48:101906. [PMID: 31865196 DOI: 10.1016/j.ajp.2019.101906] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the incidence of clozapine induced haematological side effects among patients receiving clozapine. METHODS Data of 333 patients who were on clozapine for a mean duration of 52.96 (45.18) months were reviewed for haematological abnormalities. RESULTS Most of the patients (n = 320; 96.1 %) were diagnosed with psychotic disorders, mainly schizophrenia. These patients were receiving clozapine in the dose range of 12.5 mg-600 mg/day, with a mean dose of 212.08 (102.43) mg/day at the time of review of their records. About one-tenth (N = 33; 9.9 %) of patients developed eosinophilia (absolute eosinophil count >600), and 8.2 % (N = 27) experienced thrombocytopenia (platelet count <100,000 cmm3) and 7 patients developed anaemia (haemoglobin level <10 gm%). Only 2 (0.6%) patients developed neutropenia. Mean dose (mg/day) at which haematological side-effects occurred were as follows: 159.85 (87.65) mg/day for eosinophilia; 193.98 (148.93) mg/day for thrombocytopenia; 78.57 (22.49) mg/day for anaemia. In a small proportion of patients, clozapine was discontinued due to the haematological abnormalities and in other patients these abnormalities normalized on its own in subsequent follow-up. CONCLUSION Clozapine is associated eosinophilia and thrombocytopenia, which are often benign and in majority of the patients these normalize with time.
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20
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Pathak H, Damodharan D, Jayasankar P, Sreeraj VS, Venkatasubramanian G. Safety of clozapine in patient with treatment resistant schizophrenia & asymptomatic constitutional macrothrombocytopenia (Harris syndrome). Asian J Psychiatr 2019; 45:121-122. [PMID: 31569026 DOI: 10.1016/j.ajp.2019.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Harsh Pathak
- Department of Psychiatry, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru, India
| | - Dinakaran Damodharan
- Department of Psychiatry, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru, India.
| | - Pavithra Jayasankar
- Department of Psychiatry, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru, India
| | - Vanteemar S Sreeraj
- Department of Psychiatry, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru, India
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru, India
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21
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Tunsirimas N, Pariwatcharakul P, Choovanichvong S, Ratta-Apha W. Clozapine-induced agranulocytosis and leukopenia: Incidence, associated factors, and rate of hematologic adverse-effects monitoring in psychiatric out-patient services in Thailand. Asian J Psychiatr 2019; 41:13-16. [PMID: 30856469 DOI: 10.1016/j.ajp.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/27/2019] [Accepted: 03/04/2019] [Indexed: 01/21/2023]
Abstract
The present study aimed to investigate the incidence of agranulocytosis and leukopenia and its associated factors in Thai schizophrenia patients treated with clozapine and the rate of hematologic adverse events monitored in clinical practice. Data were collected from the medical records of 641 outpatients at two hospitals. The results showed no cases of agranulocytosis and 20 cases of leukopenia (3.1%), 85% of which were observed after 1 year of prescription. The associated factors were female (p = 0.019) and duration of clozapine prescription (p = 0.026). According to the guideline for safety monitoring, 23.6% of cases had neutrophils count monitoring.
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Affiliation(s)
- Noppawan Tunsirimas
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Nakorn Ratchasima Rajanagarindra Psychiatric Hospital, Nakorn Ratchasima, Thailand
| | - Pornjira Pariwatcharakul
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Woraphat Ratta-Apha
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Abstract
OBJECTIVES The purpose of this article is to review the current literature on drug-induced thrombocytosis with the goal of critically assessing causality and providing a comprehensive review of the topic. Thrombopoietic growth factors, such as thrombopoietin-receptor agonists (romiplostim and eltrombopag) and erythropoietin are not included in our review. DATA SOURCES The literature search included published articles limited to the English language and humans in MEDLINE, EMBASE, and Web of Science databases. MEDLINE/PubMed (1966 to September 2018) was searched using the MeSH terms thrombocytosis/chemically-induced and thrombocytosis/etiology. EMBASE (1980 to September 2018) was searched using the EMTAGS thrombocytosis/side effect. Web of Science (1970 to September 2018) was searched using the search term thrombocytosis. References of all relevant articles were reviewed for additional citations and information. STUDY SELECTION AND DATA EXTRACTION Review articles, clinical trials, background data, case series, and case reports of drug-induced thrombocytosis were collected, and case reports were assessed for causality using a modified Naranjo nomogram. DATA SYNTHESIS Drug-induced thrombocytosis, a form of reactive thrombocytosis cannot be easily differentiated from more common etiologies of reactive thrombocytosis. In all, 43 case reports of drug-induced thrombocytosis from a wide variety of drugs and drug classes were reviewed using a modified Naranjo probability scale that included criteria specific for thrombocytosis. CONCLUSIONS Drug-induced thrombocytosis is a relatively rare adverse drug reaction. The strongest evidence of causality supports low-molecular-weight heparins and neonatal drug withdrawal. Weaker evidence exists for all-trans retinoic acid, antibiotics, clozapine, epinephrine, gemcitabine, and vinca alkaloids.
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Affiliation(s)
- Quyen T Vo
- 1 Southwestern Oklahoma State University, Weatherford, OK, USA
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Boazak M, Goldsmith DR, Cotes RO. Mask Off? Lithium Augmentation for Clozapine Rechallenge After Neutropenia or Agranulocytosis: Discontinuation Might Be Risky. Prim Care Companion CNS Disord 2018; 20. [PMID: 30549484 DOI: 10.4088/pcc.18l02282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Mina Boazak
- .,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David R Goldsmith
- PSTAR Clinic, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert O Cotes
- PSTAR Clinic, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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Hepatitis, Interstitial Nephritis, and Pancreatitis in Association With Clozapine Treatment: A Systematic Review of Case Series and Reports. J Clin Psychopharmacol 2018; 38:520-527. [PMID: 30059436 DOI: 10.1097/jcp.0000000000000922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/BACKGROUND Clozapine is the criterion standard in treatment-resistant schizophrenia. We sought to review data on several inflammatory effects associated with clozapine, specifically interstitial nephritis, hepatitis, and pancreatitis. METHODS/PROCEDURES We conducted a systematic review to identify studies, published up until December 2017, describing clozapine-induced hepatitis, nephritis, and pancreatitis. The primary objective was to characterize the clinical characteristics associated with each of the specific inflammatory reactions to clozapine. FINDINGS/RESULTS We identified 42 cases of inflammatory reactions associated with clozapine treatment- 20 :cases of clozapine-induced hepatitis, 11 cases of nephritis, and 11 of pancreatitis. The mean (SD) age was 38.8 (11.9) years. The mean (SD) dose of clozapine used was 252.4 (133.7) mg. Time to onset of pancreatitis (17.9 [11.2] days; range 4-35 days) was shorter than that for hepatitis (34.2 [20.1] days; range, 12-90 days) and nephritis (27.9 [27.0]; range, 8-90 days) but was not statistically significant (F = 2.267, P = 0.117). The mean (SD) time to recovery was shorter for cases of pancreatitis (15.7 [18.4] days) compared with cases of hepatitis (25.9 [16.5] days) and nephritis (24.5 [18.9] days). Three cases with hepatitis died. Seven of the cases had a clozapine rechallenge (hepatitis [n = 3], nephritis [n = 1], pancreatitis [n = 3]), with 5 having a recurrence at a mean (SD) onset of 3.5 (2.5) days (range, 1-7 days); 2 hepatitis cases were successfully rechallenged. IMPLICATIONS/CONCLUSIONS Clozapine-induced hepatitis, nephritis, and pancreatitis are uncommon adverse events, reflected in the paucity of case studies in the literature. Early recognition of the signs and symptoms of clozapine-associated hepatitis, nephritis, and pancreatitis is important, as when identified, clozapine should be urgently discontinued. Clozapine is associated with evidence of benign inflammatory processes; the extent to which hepatitis, and other inflammatory reactions, may be on a continuum with these more benign and self-limiting reactions is unclear, and this can only be resolved by prospectively following cohorts of clozapine-treated patients.
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25
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Mitochondrial DNA copy number is associated with psychosis severity and anti-psychotic treatment. Sci Rep 2018; 8:12743. [PMID: 30143692 PMCID: PMC6109159 DOI: 10.1038/s41598-018-31122-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 08/08/2018] [Indexed: 02/06/2023] Open
Abstract
Mitochondrial pathology has been implicated in the pathogenesis of psychotic disorders. A few studies have proposed reduced leukocyte mitochondrial DNA (mtDNA) copy number in schizophrenia and bipolar disorder type I, compared to healthy controls. However, it is unknown if mtDNA copy number alteration is driven by psychosis, comorbidity or treatment. Whole blood mtDNA copy number was determined in 594 psychosis patients and corrected for platelet to leukocyte count ratio (mtDNAcnres). The dependence of mtDNAcnres on clinical profile, metabolic comorbidity and antipsychotic drug exposure was assessed. mtDNAcnres was reduced with age (β = −0.210, p < 0.001), use of clozapine (β = −0.110,p = 0.012) and risperidone (β = −0.109,p = 0.014), dependent on prescribed dosage (p = 0.006 and p = 0.026, respectively), and the proportion of life on treatment (p = 0.006). Clozapine (p = 0.0005) and risperidone (p = 0.0126) had a reducing effect on the mtDNA copy number also in stem cell-derived human neurons in vitro at therapeutic plasma levels. For patients not on these drugs, psychosis severity had an effect (β = −0.129, p = 0.017), similar to age (β = −0.159, p = 0.003) and LDL (β = −0.119, p = 0.029) on whole blood mtDNAcnres. Further research is required to determine if mtDNAcnres reflects any psychosis-intrinsic mitochondrial changes.
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26
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Boazak M, Kahn B, Cox L, Ragazino J, Goldsmith DR, Cotes RO. Re-titration rates after clozapine-induced neutropenia or agranulocytosis: A case report and literature review. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2018:10.3371/CSRP.BOKA.061518. [PMID: 29944418 PMCID: PMC6443488 DOI: 10.3371/csrp.boka.061518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clozapine-induced neutropenia occurs in 3-5% of individuals treated with clozapine. Current US guidelines require interruption of clozapine when the absolute neutrophil count (ANC) drops below 1000 cells/mm3. There is minimal available guidance for what dosing schedule to use when restarting clozapine after an episode of neutropenia. Here, we present a case of a 50-year-old Caucasian female with a history of schizoaffective disorder who was successfully rechallenged on clozapine one month after developing clozapine-induced neutropenia (ANC 600 cells/mm3). To understand published re-titration rates of clozapine after neutropenia, we conducted a literature review using a using the PubMed database and found only seven case reports that unambiguously reported a clozapine dosing schedule during re-challenge. All were successful except one, a case of clozapine rechallenge after agranulocytosis. Including this case presentation, six out of eight cases restarted clozapine more cautiously than recommended by the US guidelines for a new clozapine initiation. We cannot comment what role a slower or more rapid titration plays in a successful rechallenge after neutropenia with the available evidence. We encourage researchers to publish their dosing schedule in detail after an episode of neutropenia or agranulocytosis.
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Affiliation(s)
- Mina Boazak
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Benjamin Kahn
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Lindsay Cox
- Department of Psychiatry & Behavioral Sciences, University of Miami Leonard Miller School of Medicine
| | - James Ragazino
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - David R. Goldsmith
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Robert O. Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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27
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Smith RL, Haslemo T, Andreassen OA, Eliasson E, Dahl ML, Spigset O, Molden E. Correlation Between Serum Concentrations of N-Desmethylclozapine and Granulocyte Levels in Patients with Schizophrenia: A Retrospective Observational Study. CNS Drugs 2017; 31:991-997. [PMID: 28948574 DOI: 10.1007/s40263-017-0469-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clozapine is restricted to use in patients with treatment-refractory schizophrenia due to the risk of a serious drop in absolute neutrophil granulocyte count (ANC). The formation of reactive, unstable metabolites (adducts) has been suggested as a mechanism of clozapine-induced granulocyte decline. These adducts are not detectable in vivo, but stable clozapine metabolites could potentially be indirect pharmacokinetic measures of adduct formation. OBJECTIVE The present retrospective observational study investigated the correlation between concentrations of N-desmethylclozapine, the major stable clozapine metabolite, and ANC in a real-life population of clozapine-treated patients. METHODS Patients were included from a therapeutic drug monitoring service at the Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway, between March 2005 and December 2015. Information about clozapine and N-desmethylclozapine steady-state trough concentrations, as well as accompanying measurements of ANC, were collected from the laboratory database. Correlations of serum concentrations of N-desmethylclozapine and clozapine (and their respective ratios) with ANC were investigated by linear mixed-model analysis. RESULTS Overall, 129 patients with 855 measurements of clozapine/N-desmethylclozapine concentrations and ANC (range 0.9-19 × 109 cells/L, median 4.6) were included. Concentrations of N-desmethylclozapine, but not clozapine, correlated significantly and positively with ANC (estimated model slope 0.0011 × 109 cells/L/nM; p = 0.002), and the N-desmethylclozapine/clozapine ratio also positively correlated with ANC (p = 0.040). CONCLUSIONS N-Desmethylclozapine level and ANC significantly correlated in this real-life population of schizophrenia patients. The positive correlation, which was also present for the metabolic ratio, might reflect reduced clozapine availability for the formation of reactive metabolites potentially affecting granulocyte level. However, as our findings were based on ANC mainly within the reference range, this hypothesis should be studied further in clozapine-treated patients with neutropenia or agranulocytosis.
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Affiliation(s)
- Robert L Smith
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tore Haslemo
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ole A Andreassen
- Division of Mental Health and Addiction, NORMENT and K.G. Jebsen Centre for Psychosis Research, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Erik Eliasson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marja-Liisa Dahl
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway. .,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway.
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28
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Clozapine versus other antipsychotics during the first 18 weeks of treatment: A retrospective study on risk factor increase of blood dyscrasias. Psychiatry Res 2017. [PMID: 28651220 DOI: 10.1016/j.psychres.2017.06.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Blood dyscrasias excluding agranulocytosis received limited attention in antipsychotic-treated patients during the first 18 weeks of therapy, although severe clinical conditions have been reported in a few cases. We extracted data records of 285 Caucasian patients after 18 weeks of antipsychotic treatments to investigate risk factors of blood dyscrasias. We observed a higher risk to develop both transient and persistent anemia, neutrophilia and eosinophilia in clozapine-treated patients, whereas in those treated with other atypical antipsychotics when compared to a reference group under typical antipsychotics, emerged an increased risk for transient neutrophilia and eosinophilia. Male patients revealed a higher risk of persistent eosinophilia, neutrophilia, and leukocytosis. Concomitant treatments with mood stabilizers or benzodiazepines proved to be risk factors for transient anemia, antidepressants for transient eosinophilia. Severe complications emerged in 3 cases of agranulocytosis. Cross-tabulation analysis showed a higher probability of a poor response in clozapine-treated patients with persistent anemia and a positive with persistent neutrophilia and eosinophilia. Our data evidenced that emerging blood dyscrasias were not associated with critical adverse effects, and only agranulocytosis required a treatment interruption. Other atypical antipsychotics might represent a viable alternative to potentially harmful clozapine and typical antipsychotics at the onset of life-threatening haematological alterations.
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29
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Finsterer J, Zarrouk-Mahjoub S. Clozapine for mitochondrial psychosis. Mol Genet Metab Rep 2017; 10:50. [PMID: 28070497 PMCID: PMC5219592 DOI: 10.1016/j.ymgmr.2016.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 12/31/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Vienna, Austria
- Corresponding author at: Postfach 20, 1180 Vienna, Austria.Postfach 20Vienna1180Austria
| | - Sinda Zarrouk-Mahjoub
- University of Tunis El Manar, Genomics Platform, Pasteur Institute of Tunis, Tunisia
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30
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Ho YC, Lin HL. Continuation with clozapine after eosinophilia: a case report. Ann Gen Psychiatry 2017; 16:46. [PMID: 29259655 PMCID: PMC5731207 DOI: 10.1186/s12991-017-0169-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clozapine-induced eosinophilia had been reported in several studies about blood dyscrasias in clozapine-treated patient. The largest study with 2404 patients in Italy found the incidence of 2.2% by criteria of more than 0.4 × 109/l. Associated cases of pancreatitis, hepatitis, colitis, nephritis, and myocarditis were reported. Interestingly, incidence of myocarditis is high in Australia, but low in the rest of the world. In the following, we will present a case of clozapine-induced eosinophilia which spontaneous resolution was noted under continuation of clozapine. CASE PRESENTATION "Mr. L" was a 54-year-old single, jobless man. He had treatment-resistant chronic schizophrenia with onset at age 28. He had received electroconvulsive therapy twice prior to this admission. After admission, a trial of clozapine was started with an initial dose of 100 mg/day, and gradually titrated to 200 mg/day. He experienced notable improvement after 2 weeks with decreased auditory hallucinations and no more self-harm behaviors, but he also developed eosinophilia. A medical workup was performed and showed no signs of end-organ inflammation. We continued clozapine use and closely monitored complete blood count with a differential test to track his eosinophil count by the recommendation of the hematology service. His eosinophil count decreased then and remained within normal limits 3 weeks later. The dosage of clozapine was gradually raised as high as 400 mg/day. His psychotic symptoms got partial remission and continued to show no signs of end-organ inflammation at the time of discharge. CONCLUSIONS The pathophysiology of clozapine-induced eosinophilia is still unknown, but resolution of eosinophilia despite ongoing clozapine treatment suggests the possibility of an acute allergic reaction. Signs or symptoms of organ inflammation are important for management of eosinophilia. In this case report, we demonstrated that if eosinophilia occurred without signs or symptoms of organ inflammation, it may be justified to continue clozapine use under careful monitoring.
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Affiliation(s)
- Yen-Cheng Ho
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
| | - Huang-Li Lin
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
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31
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Sahoo S, Singla H, Spoorty M, Malhotra P, Grover S. Thrombocytopenia associated with olanzapine: A case report and review of literature. Indian J Psychiatry 2016; 58:339-341. [PMID: 28066016 PMCID: PMC5100130 DOI: 10.4103/0019-5545.192005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is limited literature on olanzapine-associated thrombocytopenia. In this report, we present a case of a 32-year-old female, suffering from persistent delusional disorder who had thrombocytopenia (46,000/mm3) with the use of olanzapine 25 mg/day, 6 weeks after starting medication. Blood film did not reveal any evidence of any dysplastic cells, disturbance in the count of other cell lines, and autoimmune workup including antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were found to be negative. Given no other etiology, olanzapine was gradually tapered, and platelet counts were monitored. Reduction in the dose of olanzapine led to an improvement in platelet counts which reached the normal range after complete stoppage of olanzapine. In view of continued psychotic symptoms, she was started on clozapine and which was gradually increased to 200 mg/day with biweekly monitoring of total platelet counts before each increment in the dose of clozapine. Thrombocytopenia did not recur with use of clozapine. With clozapine, her psychosis improved by nearly 60%. A review of literature revealed only eight case reports supporting the association of olanzapine and thrombocytopenia.
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Affiliation(s)
- Swapnajeet Sahoo
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Himanshu Singla
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - M Spoorty
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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32
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Remington G, Lee J, Agid O, Takeuchi H, Foussias G, Hahn M, Fervaha G, Burton L, Powell V. Clozapine’s critical role in treatment resistant schizophrenia: ensuring both safety and use. Expert Opin Drug Saf 2016; 15:1193-203. [DOI: 10.1080/14740338.2016.1191468] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- G. Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - J. Lee
- Department of General Psychiatry 1, Institute of Mental Health, Singapore, Singapore
| | - O. Agid
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - H. Takeuchi
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - G. Foussias
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - M. Hahn
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - G. Fervaha
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - L. Burton
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - V. Powell
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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