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Gurrera RJ, Gearin PF, Love J, Li KJ, Xu A, Donaghey FH, Gerace MR. Recognition and management of clozapine adverse effects: A systematic review and qualitative synthesis. Acta Psychiatr Scand 2022; 145:423-441. [PMID: 35178700 DOI: 10.1111/acps.13406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Clozapine is substantially underutilized in most countries and clinician factors including lack of knowledge and concerns about adverse drug effects (ADEs) contribute strongly to treatment reluctance. The aim of this systematic review was to provide clinicians with a comprehensive information source regarding clozapine ADEs. METHODS PubMed and Embase databases were searched for English language reviews concerned with clozapine ADEs; publications identified by the automated search were manually searched for additional relevant citations. Following exclusion of redundant and irrelevant reports, pertinent information was summarized in evidence tables corresponding to each of six major ADE domains; two authors reviewed all citations for each ADE domain and summarized their content by consensus in the corresponding evidence table. This study was conducted in accordance with PRISMA principles. RESULTS Primary and secondary searches identified a total of 305 unique reports, of which 152 were included in the qualitative synthesis. Most clozapine ADEs emerge within 3 months, and almost all appear within 6 months, after initiation. Notable exceptions are weight gain, diabetic ketoacidosis (DKA), severe clozapine-induced gastrointestinal hypomotility (CIGH), clozapine-induced cardiomyopathy (CICM), seizures, and clozapine-induced neutropenia (CIN). Most clozapine ADEs subside gradually or respond to dose reduction; those that prompt discontinuation generally do not preclude rechallenge. Rechallenge is generally inadvisable for clozapine-induced myocarditis (CIM), CICM, and clozapine-induced agranulocytosis (CIA). Clozapine plasma levels >600-1000 μg/L appear more likely to cause certain ADEs (e.g., seizures) and, although there is no clear toxicity threshold, risk/benefit ratios are generally unfavorable above 1000 μg/L. CONCLUSION Clozapine ADEs rarely require discontinuation.
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Affiliation(s)
- Ronald J Gurrera
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Priya F Gearin
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jonathan Love
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin J Li
- Department of Psychiatry, Kaiser Permanente Fremont Medical Center, Fremont, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | - Ashley Xu
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Faith H Donaghey
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Gerace
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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2
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Dias CL, Fonseca L, Gadelha A, Noto C. Clozapine-induced hepatotoxicity: A life threatening situation. Schizophr Res 2021; 235:3-4. [PMID: 34274796 DOI: 10.1016/j.schres.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Cíntia Lopes Dias
- Department of Psychiatry, UNIFESP/EPM, Rua Pedro de Toledo, 669, 3o andar, São Paulo, SP, Brazil
| | - Lais Fonseca
- Department of Psychiatry, UNIFESP/EPM, Rua Pedro de Toledo, 669, 3o andar, São Paulo, SP, Brazil
| | - Ary Gadelha
- Department of Psychiatry, UNIFESP/EPM, Rua Pedro de Toledo, 669, 3o andar, São Paulo, SP, Brazil
| | - Cristiano Noto
- Department of Psychiatry, UNIFESP/EPM, Rua Pedro de Toledo, 669, 3o andar, São Paulo, SP, Brazil.
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3
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Platanić Arizanović L, Nikolić-Kokić A, Brkljačić J, Tatalović N, Miler M, Oreščanin-Dušić Z, Vidonja Uzelac T, Nikolić M, Milošević V, Blagojević D, Spasić S, Miljević Č. Effects of several atypical antipsychotics closapine, sertindole or ziprasidone on hepatic antioxidant enzymes: Possible role in drug-induced liver dysfunction. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2021; 84:173-182. [PMID: 33234086 DOI: 10.1080/15287394.2020.1844827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chronic use of atypical antipsychotics may produce hepatic damage. Atypical antipsychotics, including clozapine, sertindole, and ziprasidone, are extensively metabolized by the liver and this process generates toxic-free radical metabolic intermediates which may contribute to liver damage. The aim of this study was to investigate whether clozapine, sertindole, or ziprasidone affected hepatic antioxidant defense enzymes which consequently led to disturbed redox homeostasis. The expression and activity of antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GR), catalase (CAT), and glutathione-S-transferases (GST) were measured in rat livers at doses corresponding to human antipsychotic therapy. Clozapine increased activity of SOD types 1 and 2, GR and GST, but reduced CAT activity. Sertindole elevated activities of both SODs. In ziprasidone-treated rats only decreased CAT activity was found. All three antipsychotics produced mild-to-moderate hepatic histopathological changes categorized as regenerative alterations. No apparent signs of immune cell infiltration, microvesicular or macrovesicular fatty change, or hepatocytes in mitosis were observed. In conclusion, a 4-week long daily treatment with clozapine, sertindole, or ziprasidone altered hepatic antioxidant enzyme activities and induced histopathological changes in liver. The most severe alterations were noted in clozapine-treated rats. Data indicate that redox disturbances may contribute to liver dysfunction after long-term atypical antipsychotic drug treatment.
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Affiliation(s)
| | - Aleksandra Nikolić-Kokić
- Department of Physiology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Jelena Brkljačić
- Department of Biochemistry, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Nikola Tatalović
- Department of Physiology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Marko Miler
- Department of Cytology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Zorana Oreščanin-Dušić
- Department of Physiology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Teodora Vidonja Uzelac
- Department of Physiology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Milan Nikolić
- Department of Biochemistry, Faculty of Chemistry, University of Belgrade , Belgrade, Serbia
| | - Verica Milošević
- Department of Cytology, Institute for Biological Research "Siniša Stanković", National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Duško Blagojević
- Department of Biochemistry, Faculty of Chemistry, University of Belgrade , Belgrade, Serbia
| | - Snežana Spasić
- Department of Chemistry, Institute of Chemistry, Technology and Metallurgy - National Institute of Republic of Serbia, University of Belgrade , Belgrade, Serbia
| | - Čedo Miljević
- Outpatient Department, Institute of Mental Health, School of Medicine, University of Belgrade , Belgrade, Serbia
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4
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Oxidation-reduction mechanisms in psychiatric disorders: A novel target for pharmacological intervention. Pharmacol Ther 2020; 210:107520. [PMID: 32165136 DOI: 10.1016/j.pharmthera.2020.107520] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 03/02/2020] [Indexed: 12/16/2022]
Abstract
While neurotransmitter dysfunction represents a key component in mental illnesses, there is now a wide agreement for a central pathophysiological hub that includes hormones, neuroinflammation, redox mechanisms as well as oxidative stress. With respect to oxidation-reduction (redox) mechanisms, preclinical and clinical evidence suggests that an imbalance in the pro/anti-oxidative homeostasis toward the increased production of substances with oxidizing potential may contribute to the etiology and manifestation of different psychiatric disorders. The substantial and continous demand for energy renders the brain highly susceptible to disturbances in its energy supply, especially following exposure to stressful events, which may lead to overproduction of reactive oxygen and nitrogen species under conditions of perturbed antioxidant defenses. This will eventually induce different molecular alterations, including extensive protein and lipid peroxidation, increased blood-brain barrier permeability and neuroinflammation, which may contribute to the changes in brain function and morphology observed in mental illnesses. This view may also reconcile different key concepts for psychiatric disorders, such as the neurodevelopmental origin of these diseases, as well as the vulnerability of selective cellular populations that are critical for specific functional abnormalities. The possibility to pharmacologically modulate the redox system is receiving increasing interest as a novel therapeutic strategy to counteract the detrimental effects of the unbalance in brain oxidative mechanisms. This review will describe the main mechanisms and mediators of the redox system and will examine the alterations of oxidative stress found in animal models of psychiatric disorders as well as in patients suffering from mental illnesses, such as schizophrenia and major depressive disorder. In addition, it will discuss studies that examined the effects of psychotropic drugs, including antipsychotics and antidepressants, on the oxidative balance as well as studies that investigated the effectiveness of a direct modulation of oxidative mechanisms in counteracting the behavioral and functional alterations associated with psychiatric disorders, which supports the promising role of the redox system as a novel therapeutic target for the improved treatment of brain disorders.
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5
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Prieto de Paula JM, Martín-Luquero Ibáñez M, Martín Guerra J, Cepedello Pérez S, Franco Hidalgo S, Prieto Dehesa M, Martín Asenjo M. Clozapina and acute hepatitis. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2020; 13:49-50. [PMID: 30971381 DOI: 10.1016/j.rpsm.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/17/2018] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Affiliation(s)
| | | | - Javier Martín Guerra
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Sandra Cepedello Pérez
- Servicio de Psiquiatría, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Silvia Franco Hidalgo
- Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - Mario Prieto Dehesa
- Medicina Familiar y Comunitaria, Centro de Salud Covaresa, Valladolid Oeste, Valladolid, España
| | - Miguel Martín Asenjo
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, España
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6
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Castanheira L, Fernandes E, Levy P, Coentre R. Aripiprazole-induced Hepatitis: A Case Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:551-555. [PMID: 31671495 PMCID: PMC6852676 DOI: 10.9758/cpn.2019.17.4.551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/27/2018] [Accepted: 06/26/2018] [Indexed: 12/19/2022]
Abstract
Aripiprazole is an atypical antipsychotic that acts as a partial agonist of dopamine type 2 receptors as well as 5-HT1A receptors. It is used in the treatment of schizophrenia and in type 1 bipolar disorder for mania. Because aripiprazole is well tolerated with few side effects it is used off-label in other psychotic disorders. The prevalence of abnormal liver function tests with antipsychotic use is 32%, with clinically significant effects in 4% of cases. No cases of aripiprazole-induced liver injury have been published. We report a 28-year-old female who presented with non-affective first-episode psychosis and who was treated with aripiprazole. Initially she was medicated with 10 mg per day, with an increase to 20 mg per day on the 12th day of hospitalization. Nine days after she became icteric, with nausea and had a vomiting episode. Laboratory analysis revealed a very high level of alanine aminotransferase, and minor to moderately high levels of aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. Aripiprazole was tapered and paliperidone was started with the improvement of clinical and laboratory findings.
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Affiliation(s)
- Lígia Castanheira
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Elsa Fernandes
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Pedro Levy
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Ricardo Coentre
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal.,Clínica Universitária de Psiquiatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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7
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Telles-Correia D, Barbosa A, Cortez-Pinto H, Campos C, Rocha NBF, Machado S. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity. World J Gastrointest Pharmacol Ther 2017; 8:26-38. [PMID: 28217372 PMCID: PMC5292604 DOI: 10.4292/wjgpt.v8.i1.26] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/02/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023] Open
Abstract
The liver is the organ by which the majority of substances are metabolized, including psychotropic drugs. There are several pharmacokinetic changes in end-stage liver disease that can interfere with the metabolization of psychotropic drugs. This fact is particularly true in drugs with extensive first-pass metabolism, highly protein bound drugs and drugs depending on phase I hepatic metabolic reactions. Psychopharmacological agents are also associated with a risk of hepatotoxicity. The evidence is insufficient for definite conclusions regarding the prevalence and severity of psychiatric drug-induced liver injury. High-risk psychotropics are not advised when there is pre-existing liver disease, and after starting a psychotropic agent in a patient with hepatic impairment, frequent liver function/lesion monitoring is advised. The authors carefully review the pharmacokinetic disturbances induced by end-stage liver disease and the potential of psychopharmacological agents for liver toxicity.
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8
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Borges RS, Nagurniak GR, Queiroz LMD, Maia CSF, Barros CAL, Orestes E, da Silva ABF. Structure and toxicity of clozapine and olanzapine on agranulocytosis. Med Chem Res 2015. [DOI: 10.1007/s00044-015-1484-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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9
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Andreazza AC, Barakauskas VE, Fazeli S, Feresten A, Shao L, Wei V, Wu CH, Barr AM, Beasley CL. Effects of haloperidol and clozapine administration on oxidative stress in rat brain, liver and serum. Neurosci Lett 2015; 591:36-40. [PMID: 25684243 DOI: 10.1016/j.neulet.2015.02.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/08/2015] [Accepted: 02/11/2015] [Indexed: 10/24/2022]
Abstract
Antipsychotics remain the standard of care for individuals with schizophrenia, despite their association with adverse effects including extrapyramidal symptoms, metabolic syndrome and agranulocytosis. While the biological mechanisms underlying these side effects remain unresolved, it has been proposed that oxidative stress may play a role in their development. The aim of this study was to evaluate markers of oxidative stress associated with first- and second-generation antipsychotics, focusing on protein and lipid oxidation and expression of the antioxidant proteins peroxiredoxin-2 and peroxiredoxin-6. Following 28-day administration of haloperidol, clozapine or saline to adult rats, brain grey matter, white matter, serum and liver samples were obtained and lipid peroxidation, protein oxidation, peroxiredoxin-2 and peroxiredoxin-6 levels quantified. In grey matter, peroxiredoxin-6 was significantly increased in the haloperidol-exposed animals, with a trend towards increased lipid peroxidation also observed in this group. In liver, lipid peroxidation was increased in the clozapine-exposed animals, with a similar trend noted in the haloperidol group. Antipsychotics did not produce significant changes in serum or white matter. Our results suggest that haloperidol and clozapine may induce oxidative stress in brain and liver, respectively, consistent with the documented adverse effects of these agents.
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Affiliation(s)
- Ana C Andreazza
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Vilte E Barakauskas
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Salar Fazeli
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Abigail Feresten
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Li Shao
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Vivien Wei
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Che Hsuan Wu
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M Barr
- Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Clare L Beasley
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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10
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Wu Chou AI, Lu ML, Shen WW. Hepatotoxicity induced by clozapine: a case report and review of literature. Neuropsychiatr Dis Treat 2014; 10:1585-7. [PMID: 25210451 PMCID: PMC4155895 DOI: 10.2147/ndt.s67654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Clozapine is an effective antipsychotic drug but is associated with serious side effects. Most treatment guidelines give no clear recommendations on regular monitoring of liver function tests, even though up to 60% of patients experience elevations in hepatic transaminases, with 15% to 30% experiencing an elevation two to three times greater than normal. Though elevations in liver function tests are often transient and asymptomatic, there are many reported cases of clozapine-induced hepatotoxicity, with damage to the liver, involvement of multiple organs, and even fulminant liver failure arising with moderate clozapine doses. This case report describes a Chinese woman who developed hepatotoxicity on a low dose of clozapine, and reviews the relevant literature.
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Affiliation(s)
- Ana Isabel Wu Chou
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan ; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Winston W Shen
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan ; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
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Kang SH, Lee JI. Eosinophilia, pleural effusion, hepatitis, and jaundice occurring early in clozapine treatment. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2013; 11:103-5. [PMID: 24023555 PMCID: PMC3766753 DOI: 10.9758/cpn.2013.11.2.103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/25/2013] [Indexed: 12/23/2022]
Abstract
Clozapine use is associated with various adverse events, some of which have received little attention, including eosinophilia, pleural effusion, and hepatitis. Because of the fatality of jaundice with hepatitis, it is necessary to understand the course and management of clozapine-induced eosinophilia and hepatitis. We report on a case in which the eosinophil count began to increase shortly after clozapine use, and pleural effusion and fever then developed at the time eosinophilia was at its peak level. Jaundice with hepatitis consecutively developed when all the above symptoms subsided. The liver function recovered rapidly after clozapine was discontinued. We recommend that patients who develop rapid eosinophilia at the beginning of clozapine treatment should be monitored with LFTs, chest X-rays, and urine analysis tests.
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Affiliation(s)
- Shi Hyun Kang
- Department of Psychiatry, Seoul National Hospital, Seoul, Korea
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12
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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