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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 DOI: 10.1007/s40263-024-01100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Das A, Sawyer AT, Bagla P. A Rapid Review of the Effects of the COVID-19 Vaccine Among Individuals Taking Clozapine. J Clin Psychopharmacol 2024; 44:397-401. [PMID: 38639430 DOI: 10.1097/jcp.0000000000001854] [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: 04/20/2024]
Abstract
BACKGROUND The COVID-19 pandemic prompted the rapid development of vaccines to combat the virus. Several COVID-19 vaccines have proven effective in preventing infection, hospitalization, and death. Vaccination has been especially recommended for vulnerable populations, such as individuals with psychiatric illnesses who face increased risks due to comorbidities and socioeconomic factors. This rapid review identifies and analyzes the effects of COVID-19 vaccines among individuals taking clozapine. METHODS The review included articles from PubMed, OVID, Clinical Key, Web of Science, and Google Scholar, published between September 2020 and December 2023. Inclusion criteria were peer-reviewed journals, English language, patients on clozapine receiving a COVID-19 vaccine, and documented vaccine-related adverse effects. RESULTS Twelve articles were included, consisting of 8 case reports, 1 cross-sectional study, and 3 prospective observational studies, involving 298 subjects, with 9 subjects from case reports. After the first vaccine dose, 27 of 248 subjects experienced adverse effects, with 1 case report advising a temporary halt and dose reduction of clozapine. The subject in this case was admitted in a delirious state 4 days after vaccination with repeated falls and urinary incontinence; active infectious and neurologic etiologies were ruled out. Second dose data were available for 261 subjects, with 31 reporting adverse effects. Adverse effects included hematological changes, delirious state, seizures, and fever. CONCLUSIONS The review suggests that individuals on clozapine receiving COVID-19 vaccines may experience adverse effects. Clozapine levels and immune system interactions should be monitored in these cases.
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Aksar A, Lutz J, Wagner E, Strube W, Luykx JJ, Hasan A. Vaccination and clozapine use: a systematic review and an analysis of the VAERS database. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-023-01729-0. [PMID: 38165458 DOI: 10.1007/s00406-023-01729-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
In the context of COVID-19 concerns related to the potential interactions between clozapine and vaccination arose. With the ultimate goal of deriving recommendations for clinical practice, we systematically reviewed the current evidence regarding altered vaccine effectiveness in clozapine-treated patients and safety aspects of vaccination, such as haematological changes and the impact of vaccines on clozapine blood levels, in clozapine-treated patients. A systematic PRISMA-conform literature search of four databases (PubMed, PsycINFO, EMBASE and Cochrane Library) complemented by a case-by-case analysis of the Vaccine Adverse Event Reporting System (VAERS) database was performed. We then systematically appraised the joint evidence and tried to derive recommendations for clinical practice. 14 records were included in this analysis. These records consisted of 5 original articles and 9 case reports. Among the original articles, two studies provided data on the association between clozapine use and antibody responses to vaccination, both indicating that clozapine use in schizophrenia may be associated with reduced levels of immunoglobulins. Additionally, three studies examined vaccine safety in clozapine-treated patients, with no clinically significant adverse effects directly attributable to the interplay between vaccinations and clozapine. VAERS Analysis encompassed 137 reports and showed no consistent evidence of an increased risk for clozapine blood level increases or adverse events. We found no evidence indicating that clozapine impairs the effectiveness of vaccines. Moreover, no serious safety concerns seem to apply when patients on clozapine are receiving vaccines. However, it is crucial to acknowledge that data on the interaction between clozapine and vaccines remain limited.
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Affiliation(s)
- Aslihan Aksar
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Faculty of Medicine, Bezirkskrankenhaus Augsburg, University of Augsburg, Geschwister-Schoenert-Str. 1, 86156, Augsburg, Germany.
| | - Justina Lutz
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Faculty of Medicine, Bezirkskrankenhaus Augsburg, University of Augsburg, Geschwister-Schoenert-Str. 1, 86156, Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Faculty of Medicine, Bezirkskrankenhaus Augsburg, University of Augsburg, Geschwister-Schoenert-Str. 1, 86156, Augsburg, Germany
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Munich, Germany
| | - Wolfgang Strube
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Faculty of Medicine, Bezirkskrankenhaus Augsburg, University of Augsburg, Geschwister-Schoenert-Str. 1, 86156, Augsburg, Germany
| | - Jurjen J Luykx
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, The Netherlands
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Faculty of Medicine, Bezirkskrankenhaus Augsburg, University of Augsburg, Geschwister-Schoenert-Str. 1, 86156, Augsburg, Germany
- DZPG (German Center for Mental Health), Partner Site München/Augsburg, Augsburg, Germany
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Torres-Carrillo N, Martínez-López E, Torres-Carrillo NM, López-Quintero A, Moreno-Ortiz JM, González-Mercado A, Gutiérrez-Hurtado IA. Pharmacomicrobiomics and Drug-Infection Interactions: The Impact of Commensal, Symbiotic and Pathogenic Microorganisms on a Host Response to Drug Therapy. Int J Mol Sci 2023; 24:17100. [PMID: 38069427 PMCID: PMC10707377 DOI: 10.3390/ijms242317100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
Microorganisms have a close relationship with humans, whether it is commensal, symbiotic, or pathogenic. Recently, it has been documented that microorganisms may influence the response to drug therapy. Pharmacomicrobiomics is an emerging field that focuses on the study of how variations in the microbiome affect the disposition, action, and toxicity of drugs. Two additional sciences have been added to complement pharmacomicrobiomics, namely toxicomicrobiomics, which explores how the microbiome influences drug metabolism and toxicity, and pharmacoecology, which refers to modifications in the microbiome as a result of drug administration. In this context, we introduce the concept of "drug-infection interaction" to describe the influence of pathogenic microorganisms on drug response. This review analyzes the current state of knowledge regarding the relevance of microorganisms in the host's response to drugs. It also highlights promising areas for future research and proposes the term "drug-infection interaction" as an extension of pharmacomicrobiomics.
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Affiliation(s)
- Norma Torres-Carrillo
- Departamento de Microbiología y Patología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (N.T.-C.); (N.M.T.-C.)
| | - Erika Martínez-López
- Instituto de Nutrigenética y Nutrigenómica Traslacional, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico;
- Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico;
| | - Nora Magdalena Torres-Carrillo
- Departamento de Microbiología y Patología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (N.T.-C.); (N.M.T.-C.)
| | - Andres López-Quintero
- Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico;
| | - José Miguel Moreno-Ortiz
- Instituto de Genética Humana “Dr. Enrique Corona Rivera”, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (J.M.M.-O.); (A.G.-M.)
| | - Anahí González-Mercado
- Instituto de Genética Humana “Dr. Enrique Corona Rivera”, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico; (J.M.M.-O.); (A.G.-M.)
| | - Itzae Adonai Gutiérrez-Hurtado
- Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico;
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Kuzin M, Gardin F, Götschi M, Xepapadakos F, Kawohl W, Seifritz E, Trauzeddel A, Paulzen M, Schoretsanitis G. Changes in Psychotropic Drug Blood Levels After SARS-CoV-2 Vaccination: A Two-Center Cohort Study. Ther Drug Monit 2023; 45:792-796. [PMID: 37296505 DOI: 10.1097/ftd.0000000000001118] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Limited evidence from case reports suggests that coronavirus disease 2019 (COVID-19) vaccination may interact with the treatment outcomes of psychiatric medications. Apart from clozapine, reports on the effect of COVID-19 vaccination on other psychotropic agents are scarce. This study aimed to investigate the impact of COVID-19 vaccination on the plasma levels of different psychotropic drugs using therapeutic drug monitoring. METHODS Plasma levels of psychotropic agents, including agomelatine, amisulpride, amitriptyline, escitalopram, fluoxetine, lamotrigine, mirtazapine, olanzapine, quetiapine, sertraline, trazodone, and venlafaxine, from inpatients with a broad spectrum of psychiatric diseases receiving COVID-19 vaccinations were collected at 2 medical centers between 08/2021 and 02/2022 under steady-state conditions before and after vaccination. Postvaccination changes were estimated as a percentage of baseline. RESULTS Data from 16 patients who received COVID-19 vaccination were included. The largest changes in plasma levels were reported for quetiapine (+101.2%) and trazodone (-38.5%) in 1 and 3 patients, respectively, 1 day postvaccination compared with baseline levels. One week postvaccination, the plasma levels of fluoxetine (active moiety) and escitalopram increased by 31% and 24.9%, respectively. CONCLUSIONS This study provides the first evidence of major changes in the plasma levels of escitalopram, fluoxetine, trazodone, and quetiapine after COVID-19 vaccination. When planning COVID-19 vaccination for patients treated with these medications, clinicians should monitor rapid changes in bioavailability and consider short-term dose adjustments to ensure safety.
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Affiliation(s)
- Maxim Kuzin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Fabian Gardin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - Markus Götschi
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - Franziskos Xepapadakos
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Wolfram Kawohl
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | | | - Michael Paulzen
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- Alexianer Hospital Aachen, Aachen, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA-Translational Brain Medicine, Aachen, Germany
| | - Georgios Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, New York, New York; and
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
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Nakamura M, Nagamine T. Omicron Variant Infection May Not Exert an Influence on Serum Levels of Clozapine. J Clin Psychopharmacol 2023; 43:475-476. [PMID: 37683246 DOI: 10.1097/jcp.0000000000001733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
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