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Corbeil O, Béchard L, Fournier É, Plante M, Thivierge MA, Lafrenière CÉ, Huot-Lavoie M, Brodeur S, Essiambre AM, Roy MA, Demers MF. Clozapine rechallenge or continuation despite neutropenia or agranulocytosis using colony-stimulating factor: A systematic review. J Psychopharmacol 2023; 37:370-377. [PMID: 36794520 PMCID: PMC10363950 DOI: 10.1177/02698811231154111] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Rechallenge/continuation of clozapine in association with colony-stimulating factors (CSFs) following neutropenia/agranulocytosis has been reported, but many questions remain unanswered about efficacy and safety. This systematic review aims to assess the efficacy and safety of rechallenging/continuing clozapine in patients following neutropenia/agranulocytosis using CSFs. METHODS MEDLINE, Embase, PsycInfo, and Web of Science databases were searched from inception date to July 31, 2022. Articles screening and data extraction were realized independently by two reviewers, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 systematic review guidance. Included articles had to report on at least one case where clozapine was rechallenged/continued using CSFs despite previous neutropenia/agranulocytosis. RESULTS Eight hundred forty articles were retrieved; 34 articles met the inclusion criteria, totaling 59 individual cases. Clozapine was successfully rechallenged/continued in 76% of patients for an average follow-up period of 1.9 years. There was a trend toward better efficacy reported in case reports/series, compared with consecutive case series (overall success rates of 84% and 60%, respectively, p-value = 0.065). Two administration strategies were identified, "as-needed" and prophylactic, both yielding similar success rates (81% and 80%, respectively). Only mild and transient adverse events were documented. CONCLUSIONS Although limited by the relatively small number of published cases, factors such as time of onset to first neutropenia and severity of the episode did not seem to impact the outcome of a subsequent clozapine rechallenge using CSFs. While the efficacy of this strategy remains to be further adequately evaluated in more rigorous study designs, its long-term innocuity warrants considering its use more proactively in the management of clozapine hematological adverse events as to maintain this treatment for as many individuals as possible.
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Affiliation(s)
- Olivier Corbeil
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Laurent Béchard
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Émilien Fournier
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Maude Plante
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada
| | - Marc-André Thivierge
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Maxime Huot-Lavoie
- CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Sébastien Brodeur
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Anne-Marie Essiambre
- CERVO Brain Research Centre, Québec City, QC, Canada.,School of Psychology, Faculty of Social Sciences, Université Laval, Québec City, QC, Canada
| | - Marc-André Roy
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Marie-France Demers
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
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Saito T, Usui T, Inada H, Miyawaki I, Mizuno K, Ikeda M, Iwata N. Clozapine-specific proliferative response of peripheral blood-derived mononuclear cells in Japanese patients with clozapine-induced agranulocytosis. J Psychopharmacol 2022; 36:1087-1094. [PMID: 35861221 DOI: 10.1177/02698811221112937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although clozapine-induced granulocytopenia (CIG) is less severe than clozapine-induced agranulocytosis (CIA), and some patients with CIG may not go on to develop serious complications, clozapine is discontinued in cases of both CIA and CIG. Understanding the pathogenic mechanisms of CIA/CIG could provide better management of clozapine therapy. Recently, as a mechanistic insight into adaptive immune systems, European groups reported clozapine-specific proliferative responses and clozapine-specific T cells using blood taken from patients with CIA and/or CIG. AIMS The aims of our study are to support this mechanistic evidence and to investigate the difference in the lymphocyte response to clozapine between patients with CIG and those with CIA. METHODS Lymphocyte stimulation tests (LSTs) were conducted using CD25-positive cell-depleted peripheral blood-derived mononuclear cells (PBMCs) isolated from blood of four Japanese patients with CIA, four patients with CIG, and nine clozapine-tolerant subjects. RESULTS Three of four patients with CIA and one of four patients with CIG showed proliferative responses to clozapine with a stimulation index of greater than 2. In contrast, none of the nine clozapine-tolerant subjects showed any response to clozapine. Olanzapine did not stimulate PBMCs of patients with CIA, patients with CIG, or clozapine-tolerant subjects. CONCLUSIONS Clozapine- and CIA-specific lymphocyte reactions in a Japanese population provided supportive evidence that the pathogenesis of CIA is based on adaptive immune reactions. In addition, patients with CIG who show a positive response to an LST may at the very least not be chosen for clozapine-rechallenge and further prospective studies are desirable to verify this hypothesis.
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Affiliation(s)
- Takeo Saito
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toru Usui
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Hiroshi Inada
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | - Izuru Miyawaki
- Preclinical Research Unit, Sumitomo Pharma Co., Ltd., Osaka, Japan
| | | | - Masashi Ikeda
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, School of Medicine, Fujita Health University, Aichi, Japan
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Béchard L, Corbeil O, Plante M, Thivierge MA, Lafrenière CÉ, Roy MA, Demers MF. Clozapine rechallenge following neutropenia using granulocyte colony-stimulating factor: A Quebec case series. J Psychopharmacol 2021; 35:1152-1157. [PMID: 34229529 PMCID: PMC8436292 DOI: 10.1177/02698811211029737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine has a unique efficacy profile among individuals suffering from treatment-resistant schizophrenia, but is associated with hematological side effects. The use of granulocyte colony-stimulating factors (G-CSF) to allow clozapine continuation or rechallenge has emerged as a promising option, but evidence is still scarce. AIM To describe the largest case series so far published regarding this practice. METHOD A national clozapine hematological monitoring database was consulted to identify all patients who had had neutrophil count <1.5 × 109/L since 2004 in Quebec and was cross-referenced with hospital pharmacy software to identify patients who had received at least one dose of G-CSF, such as filgrastim, while being exposed to clozapine. All data were collected retrospectively, using patients' medical files, from January to July 2019. RESULTS Using G-CSF, three out of eight patients could maintain clozapine despite neutropenia episodes that otherwise would have required treatment discontinuation. The only side effect reported was mild short-lived back pain, over a mean 3-year follow-up period. In all but one case, filgrastim was used on an "as-needed" basis at doses of 300 mcg administered subcutaneously. CONCLUSION These results suggest that the "as-needed" use of G-CSF is well-tolerated and may allow clozapine rechallenge in some well-selected patients, adding to the paucity of data regarding long-term safety and efficacy of this strategy. More research may help to better define potential candidates and optimal regimen of such practice.
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Affiliation(s)
- Laurent Béchard
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada,Laurent Béchard, Clinique Notre-Dame des Victoires, 2525, chemin de la Canardière, Entrée #A-1-2, Québec (Québec), Canada G1J 2G3.
| | - Olivier Corbeil
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada
| | - Maude Plante
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada
| | - Marc-André Thivierge
- Faculté de pharmacie, Université Laval, Québec, Canada,Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke, Quebec, Canada
| | | | - Marc-André Roy
- Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Département de psychiatrie et neurosciences, Faculté de médecine, Université Laval, Canada,Centre de recherche CERVO, Québec, Canada
| | - Marie-France Demers
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada
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Abstract
BACKGROUND Clozapine is widely prescribed for treatment-refractory schizophrenia, but its use is limited by many potentially life-threatening adverse effects. The risk of rechallenge after these complications has never been comprehensively assessed in controlled studies. Thus, clinical guidelines must rely on the published case reports. The number of such reports is likely to increase over time, and updated analyses of larger samples are needed, as they may lead to changes in clinical guidelines. STUDY QUESTIONS How safe is the clozapine rechallenge after life-threatening adverse effects? STUDY DESIGN The published case reports of clozapine rechallenge were identified in a MEDLINE search. We added 121 cases reported from 2012 through 2017 to the 138 cases reported from 1972 through 2011 analyzed by us in a previous publication. The 95% confidence intervals (CIs) of the successful rechallenge rate were calculated for each adverse effect with at least 5 published case reports. The rechallenge was considered a valid clinical option when the lower end of the CI range was at least 50%. RESULTS A successful outcome was documented in 128/203 patients rechallenged after neutropenia (63.0%, CI, 56.0%-69.6%), 3/17 after agranulocytosis (17.7%, CI, 4.7%-44.2%), 11/17 after myocarditis (64.7%, CI, 38.6%-84.7%), and 7/7 after neuroleptic malignant syndrome (100%, CI, 56.1%-100%). Among the 15 patients with other clozapine-induced adverse effects, the rechallenge was successful in those with eosinophilia, cardiac complications other than myocarditis (QTc prolongation, pericarditis, cardiomyopathy, and atrial flutter), and gastrointestinal hypomotility. The rechallenge failed in patients who had developed pancreatitis or renal insufficiency. CONCLUSION Clozapine rechallenge is a reasonable clinical option after return to baseline for patients who had developed neutropenia and neuroleptic malignant syndrome, but not after agranulocytosis or myocarditis. Data are insufficient to formulate rechallenge guidelines for any other clozapine-related adverse effects.
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Karst A, Lister J. Utilization of G-CSF and GM-CSF as an alternative to discontinuation in clozapine-induced neutropenia or leukopenia: A case report and discussion. Ment Health Clin 2018; 8:250-255. [PMID: 30206510 PMCID: PMC6125119 DOI: 10.9740/mhc.2018.09.250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Clozapine remains the definitive gold standard for treatment-resistant schizophrenia despite limitations in use because of hematological abnormalities. Neutropenia or leukopenia are often treated with interruption of clozapine treatment, frequently resulting in clinical decompensation, hospitalization, increased burden to patient care, and increased risk of suicide. Colony-stimulating factors, including granulocyte colony-stimulating factors and granulocyte-macrophage colony-stimulating factors, are cytokines that stimulate proliferation and differentiation of myeloid precursor cells. Their use in the prevention and treatment of clozapine-associated neutropenia presents an alternative to clozapine discontinuation in certain cases. We present a case report of successful periodic granulocyte-macrophage colony-stimulating factor use with clozapine in a patient with treatment-resistant schizophrenia, as well as discussion of a practical approach to patients with possible clozapine-induced neutropenia or leukopenia.
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Affiliation(s)
- Allison Karst
- (Corresponding author) PGY-1 Pharmacy Resident, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee,
| | - Jonathan Lister
- Mental Health Clinical Pharmacy Specialist, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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6
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Abstract
PURPOSE/BACKGROUND Clozapine is associated with hematological abnormalities, with neutropenia and agranulocytosis of most concern. Granulocyte colony-stimulating factor (G-CSF) has been used to support clozapine rechallenge after neutropenia with the aim of maintaining the neutrophil count. This study aims to explore the practice, use, safety, and efficacy of G-CSF in this context. METHODS/PROCEDURES We conducted a systematic review to identify all studies investigating or describing G-CSF as a prophylaxis to enable continued clozapine treatment during a rechallenge. FINDINGS/RESULTS We identified 32 reports of patients who received G-CSF either regularly (n = 23) or as required (n = 9) to support clozapine rechallenge after an episode of neutropenia necessitating discontinuation of clozapine. Seventy-five percent (n = 24) of published cases remained on clozapine with the use of continual prophylactic G-CSF or after single G-CSF administrations (n = 8). Seventy percent (n = 16) of patients in receipt of continual prophylactic G-CSF were successfully maintained on clozapine. However, 1 of the 3 episodes of rechallenge in those with a history of severe agranulocytosis (absolute neutrophil count <0.1 × 10/L) had a recurrence of agranulocytosis at week 9. IMPLICATIONS/CONCLUSIONS Our findings suggest that G-CSF can sometimes be safely used to support the maintenance of normal neutrophil counts and clozapine use after neutropenia. Publication bias is an important limitation, however. Also, few reports clearly documented the presence or absence of an independent nonclozapine cause of the index neutropenia, which may have increased success rates. Furthermore, adverse events were not systematically recorded. Prospective studies are needed to determine safety because if agranulocytosis occurs on clozapine while supported by G-CSF, there is no obvious alternate rescue therapy to promote granulopoiesis. From the available data, it is not possible to recommend this course of action for someone with a true clozapine agranulocytosis.
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7
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Myles N, Myles H, Clark SR, Bird R, Siskind D. Use of granulocyte-colony stimulating factor to prevent recurrent clozapine-induced neutropenia on drug rechallenge: A systematic review of the literature and clinical recommendations. Aust N Z J Psychiatry 2017; 51:980-989. [PMID: 28747065 DOI: 10.1177/0004867417720516] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia; however, its use is contraindicated in people who have had previous clozapine-induced neutropenia. Co-prescription of granulocyte-colony stimulating factor may prevent recurrent neutropenia and allow continuation or rechallenge of clozapine. OBJECTIVE AND METHODS Systematic review of literature reporting the use of granulocyte-colony stimulating factor to allow rechallenge or continuation of clozapine in people with previous episodes of clozapine-induced neutropenia. The efficacy of granulocyte-colony stimulating factor and predictors of successful rechallenge will be determined to elucidate whether evidence-based recommendations can be made regarding the use of granulocyte-colony stimulating factor in this context. RESULTS A total of 17 articles were identified that reported on clozapine rechallenge with granulocyte-colony stimulating factor support. In all, 76% of cases were able to continue clozapine at median follow-up of 12 months. There were no clear clinical or laboratory predictors of successful rechallenge; however, initial neutropenia was more severe in successful cases compared to unsuccessful cases. Cases co-prescribed lithium had lower success rates of rechallenge (60%) compared to those who were not prescribed lithium (81%). The most commonly reported rechallenge strategy was use of filgrastim 150-480 µg between daily to three times a week. There were no medication-specific side effects of granulocyte-colony stimulating factor reported apart from euphoria in one case. Three cases who failed granulocyte-colony stimulating factor had bacterial infection at time of recurrent neutropenia. No deaths were reported. CONCLUSION Preliminary data suggest granulocyte-colony stimulating factor is safe and effective in facilitating rechallenge with clozapine. Clinical recommendations for use are discussed.
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Affiliation(s)
- Nicholas Myles
- 1 Haematology Directorate, SA Pathology, Adelaide, SA, Australia.,2 School of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Hannah Myles
- 3 Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia.,4 Country Health SA, Glenside, SA, Australia
| | - Scott R Clark
- 3 Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia
| | - Robert Bird
- 5 Division of Cancer Services, Princess Alexandra Hospital, Wooloongabba, QLD, Australia.,6 School of Medicine, Griffith University, Nathan, QLD, Australia
| | - Dan Siskind
- 2 School of Medicine, University of Queensland, St Lucia, QLD, Australia.,7 Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
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Elmore H, Lewin J, Bradley M, Sinkman A. Use of Granulocyte Colony-Stimulating Factor in a Neutropenic HIV-Infected Patient on Clozapine. PSYCHOSOMATICS 2016; 57:651-654. [PMID: 27720385 DOI: 10.1016/j.psym.2016.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Hudson Elmore
- Department of Psychiatry, New York University School of Medicine, New York, NY.
| | - Justin Lewin
- Department of Psychiatry, New York University School of Medicine, New York, NY
| | - Mark Bradley
- Department of Psychiatry, New York University School of Medicine, New York, NY; Department of Psychiatry, Veterans Affairs New York Harbor Healthcare System, New York, NY
| | - Arthur Sinkman
- Department of Psychiatry, New York University School of Medicine, New York, NY; Department of Psychiatry, Veterans Affairs New York Harbor Healthcare System, New York, NY
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Simon L, Cazard F. [Clozapine rechallenge after neutropenia in resistant schizophrenia: A review]. Encephale 2016; 42:346-53. [PMID: 27109327 DOI: 10.1016/j.encep.2016.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 03/02/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Clozapine is an atypical antipsychotic known for its efficacy in refractory schizophrenia. One of the adverse effects is neutropenia. This dysplasia is a rare but major side effect which leads to a discontinuation and constitutes further contraindication. Thereafter, therapeutic options decrease dramatically. Mechanisms involved are not well known at this time and can be combined. A toxic hypothesis may be more likely than an immune-allergic one. METHODS We have reviewed publications on Medline describing procedures that allowed clozapine rechallenge after blood dyscrasia in refractory schizophrenia. Three different procedures were found: simple rechallenge, rechallenge with lithium and rechallenge with Granulocyte - colony stimulating factor (G-CSF). Rechallenge could be simple or multiple. RESULTS These past years, clozapine have been rechallenged successfully after neutropenia thanks to different procedures, the different options being simple rechallenge, rechallenge with lithium and/or rechallenge with G-CSF. Lithium as G-CSF are used to increase neutrophil blood rate and prevent neutropenia recurrence after clozapine rechallenge. G-CSF was first used within the context of chemotherapy and extends now to clozapine-induced neutropenia. Both for lithium and G-CSF, numerous procedures are reviewed and cannot be compared. DISCUSSION Publications are limited but increasing, and they point out that a careful rechallenge can be successful. However, interesting data can be extracted. First, clozapine is more likely to be incriminated in neutropenia when patients receive many drugs, but a careful study could prevent some discontinuation. Indeed, other drugs or a hematologic disease could be involved. Moreover, several contributing factors have been found such as HLA group and drug interaction. Ethnic origin also affects neutrophil rate. That is why, in Great Britain, a subgroup of patients "benign ethnic neutropenia" has been introduced to enlarge threshold and allow these patients to access clozapine despite lower blood counts. Then, rechallenge choice has to be done on a case-by-case basis and only after considering the benefits and risks of such a treatment. Most of the time, clinical advice of rechallenge arises from the inefficiency of other antipsychotics and even sismotherapy failure. Patients and sometimes families have to be informed and give their consent. Preventive measures have been found such as taking a hematologic recommendation and doing twice-a-week blood sample monitoring. With regards lithium and G-CSF, some efficient doses are assumed (lithium: 0,4-1,1 mEq/L and G-CSF>0,3 mg/week). Lithium as G-CSF may have other adverse effects which need to be considered. There is no successful rechallenge reported after agranulocytosis. Some publications highlight that if neutropenia occurs on rechallenge, it will do so more quickly and more severe than at the time of initial trial of clozapine. CONCLUSION There is emerging evidence of successful clozapine rechallenging. However, further investigations are required as randomized controlled trials to reassess guidelines and establish the safety and effectiveness of the different procedures. Because of the practical and ethical difficulties of designing such studies, referral hospitals could be elected, and common background writing proposed in order to ease data comparison.
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Affiliation(s)
- L Simon
- Centre hospitalier interdépartemental de psychiatrie de l'enfant et de l'adolescent « Fondation Vallée », faculté de médecine Paris Sud, 7, rue Benserade, 94257 Gentilly cedex, France
| | - F Cazard
- Centre hospitalier interdépartemental de psychiatrie de l'enfant et de l'adolescent « Fondation Vallée », faculté de médecine Paris Sud, 7, rue Benserade, 94257 Gentilly cedex, France.
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Successful Use of Single Doses of Granulocyte-Colony Stimulating Factor (G-CSF) in the Treatment of Late-Onset Agranulocytosis Associated With Clozapine in a Patient With Treatment-Resistant Schizophrenia: A Case Report. J Clin Psychopharmacol 2016; 36:173-4. [PMID: 26859277 DOI: 10.1097/jcp.0000000000000467] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Khan AA, Harvey J, Sengupta S. Continuing clozapine with granulocyte colony-stimulating factor in patients with neutropenia. Ther Adv Psychopharmacol 2013; 3:266-71. [PMID: 24167701 PMCID: PMC3805383 DOI: 10.1177/2045125313476877] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current guidelines dictate that clozapine should be stopped following the emergence of neutropenia. Various alternative approaches have been tried in the past, among them one rarely used alternative being to continue treatment with clozapine with coprescription of granulocyte colony-stimulating factor (G-CSF). AIM AND METHOD In this case series we aim to describe the treatment and progress of a number of patients in a secure psychiatric hospital in the UK. These patients were restarted on clozapine in combination with G-CSF, in spite of previous neutropenia associated with clozapine treatment. DISCUSSION AND CONCLUSION We hope that this case series will raise the profile of a potentially effective alternative to discontinuing clozapine after neutropenia.
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Affiliation(s)
- Al Aditya Khan
- Consultant in Forensic Psychiatry, Bracton Centre, Bracton Lane, Dartford, Kent DA2 7AF, UK
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12
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Ojong M, Allen SN. Management and prevention of agranulocytosis in patients receiving clozapine. Ment Health Clin 2013. [DOI: 10.9740/mhc.n166825] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clozapine is an antipsychotic associated with superior efficacy compared to other atypical antipsychotics in the treatment of schizophrenia. However, clozapine use is limited due to its association with a rare but potentially fatal adverse effect, agranulocytosis. Patients receiving clozapine therapy require frequent monitoring of white blood cell (WBC) and absolute neutrophil counts (ANC). This article reviews the monitoring parameters for patients receiving clozapine therapy, and the management and prevention of clozapine-associated agranulocytosis.
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Affiliation(s)
- Mebanga Ojong
- 1 Philadelphia College of Osteopathic Medicine School of Pharmacy
| | - Shari N. Allen
- 2 Assistant Professor of Pharmacy Practice, Philadelphia College of Osteopathic Medicine School of Pharmacy
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13
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Toni-Uebari TK, Rees J. Successful rechallenge with clozapine following 'red alert'. BMJ Case Rep 2013; 2013:bcr-2012-007172. [PMID: 23345473 DOI: 10.1136/bcr-2012-007172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A case is presented of a 23-year-old lady with treatment-resistant schizoaffective disorder who had responded well to treatment with clozapine. Fifteen months after satisfactory use of clozapine she had 'red alerts' from routine haematological monitoring indicating neutropenia. Clozapine was discontinued and she was admitted to the psychiatric hospital to manage the aftermath of discontinuing clozapine and start alternative treatment with other antipsychotics. Her mental health rapidly deteriorated. Adequate trials with amisulpride, haloperidol, olanzapine and flupenthixol decanoate yielded little improvement in her clinical state. After 9 months of non-response to other antipsychotic medications, she was rechallenged with clozapine, followed by improvement in her mental state. She was eventually discharged home after 14 months of hospitalisation in a stable mental state. She remained mentally stable in the community on clozapine for 18 months after rechallenge, with no further red alerts.
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14
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Spencer BWJ, Williams HRJ, Gee SH, Whiskey E, Rodrigues JP, Mijovic A, MacCabe JH. Granulocyte colony stimulating factor (G-CSF) can allow treatment with clozapine in a patient with severe benign ethnic neutropaenia (BEN): a case report. J Psychopharmacol 2012; 26:1280-2. [PMID: 22719015 DOI: 10.1177/0269881112450782] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clozapine is the treatment of choice for treatment-resistant schizophrenia, but it is associated with a risk of neutropaenia and agranulocytosis. Clozapine use is regulated by mandatory blood monitoring in the UK, requiring cessation of treatment should the absolute neutrophil count (ANC) drop below specified values. Benign reductions in the ANC in non-white populations are common, and this can preclude a patient from receiving treatment with clozapine. A diagnosis of benign ethnic neutropaenia can reduce these treatment restrictions (UK specific), but the degree of neutropaenia can be significant enough to still prevent treatment. In this report, we show that response to granulocyte colony stimulating factor (G-CSF) may be quite variable and difficult to predict, but with careful monitoring it can be used to increase the ANC count and allow continued treatment with clozapine.
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Manu P, Sarpal D, Muir O, Kane JM, Correll CU. When can patients with potentially life-threatening adverse effects be rechallenged with clozapine? A systematic review of the published literature. Schizophr Res 2012; 134:180-6. [PMID: 22113154 PMCID: PMC3318984 DOI: 10.1016/j.schres.2011.10.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 10/20/2011] [Accepted: 10/24/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine is widely prescribed for treatment refractory patients with schizophrenia, but its use is limited by potentially life threatening adverse effects. Rechallenge after these complications has been occasionally attempted in patients with severe psychotic symptoms. OBJECTIVE To review the outcome of clozapine rechallenge after potentially life threatening adverse effects. METHODS Electronic, all-language, literature search (1972-2011) followed by demographic and clinical data extraction. The outcome of rechallenge was considered favorable when the lower bound of the 95% confidence interval (CI) of the proportion of patients who could continue clozapine was >50%. RESULTS Altogether, 138 patients (mean age: 36.3years, 65.7% male, 57.6% Caucasian, virtually all with schizophrenia spectrum diagnosis) underwent clozapine rechallenge after developing neutropenia (n=112), agranulocytosis (n=15), neuroleptic malignant syndrome (NMS) (n=5), myocarditis (n=4), pericarditis (n=1) and lupus erythematosus (n=1). Rechallenge strategies were heterogeneous and not systematically evaluated. Clozapine rechallenge was successful in 78/112 patients (69.6%, CI: 60.6-77.4) after neutropenia, 3/15 (20%, CI: 7.1-45.2) after agranulocytosis, 5/5 (100%, CI: 56-100) after NMS, 3/4 (75%, CI: 30-95) after myocarditis, 1/1 after pericarditis, and 0/1 after clozapine-induced lupus. Successfully rechallenged patients were followed for 16-96weeks. None of the rechallenged patients died. CONCLUSIONS Although controlled studies are clearly needed, using a priori, confidence interval-based criteria, case reports/series suggest that in refractory patients who benefited from clozapine, careful rechallenge can be considered after neutropenia and NMS, but not after agranulocytosis and myocarditis.
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Affiliation(s)
- Peter Manu
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Deepak Sarpal
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - Owen Muir
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - John M. Kane
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
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Nooijen PMM, Carvalho F, Flanagan RJ. Haematological toxicity of clozapine and some other drugs used in psychiatry. Hum Psychopharmacol 2011; 26:112-9. [PMID: 21416507 DOI: 10.1002/hup.1181] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 01/19/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review recent work on the haematological toxicity of clozapine and some other drugs used in psychiatry concerning especially (i) the mechanism of antipsychotic-induced neutropenia/agranulocytosis, (ii) criteria for clozapine prescribing in benign ethnic neutropenia, (iii) options in the event of worrying falls in white cell count (WCC), including measures to boost WCC with or without continued clozapine administration, (iv) criteria for clozapine rechallenge in the event that treatment was suspended because of a fall in WCC and (v) safety concerns regarding clozapine in children/adolescents. CONCLUSIONS There remain several difficult areas, including the criteria for clozapine rechallenge. Experience has emphasised (i) the role of appropriate timing of WCC sample collection to ensure that clozapine is not withdrawn unnecessarily and (ii) the success of agents such as filgrastim in promoting rapid production of granulocytes if the situation so demands. On the other hand, the use of lithium to promote a leucocytosis has taken hold without a clear risk: benefit analysis. Be this as it may, should patients decide that they no longer wish to undergo WCC monitoring after 12 months on clozapine, cessation of monitoring is probably preferable to stopping the drug since overall mortality is decreased in patients treated with clozapine.
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Affiliation(s)
- Patty M M Nooijen
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
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Opgen-Rhein C, Dettling M. Clozapine-induced agranulocytosis and its genetic determinants. Pharmacogenomics 2008; 9:1101-11. [DOI: 10.2217/14622416.9.8.1101] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Clozapine-induced agranulocytosis (CiA) is a potentially life-threatening pharmacological adverse drug reaction, which limits a broader application of this highly effective atypical antipsychotic in schizophrenic patients. Although this adverse reaction has been well known for almost 30 years, only few genetically based determinants can be identified to date. Furthermore, owing to rare occurrence, specific clinical course and complexity of pathomechanisms of antipsychotic-induced agranulocytosis, only a few of the findings met the criteria of replication. The most promising susceptibility genes for CiA include genes involved in the human leukocyte antigen system and in specific metabolizing enzyme systems. However, complex idiosyncratic drug reactions such as CiA are considered to be determined by multiple, possibly interacting genetic variations, rather than by a single causative variant.
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Affiliation(s)
- Carolin Opgen-Rhein
- Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin, Eschenallee 3, 14050 Berlin, Germany
| | - Michael Dettling
- Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin, Eschenallee 3, 14050 Berlin, Germany
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