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Mercier C, Rollason V, Eshmawey M, Mendes A, Frisoni GB. The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations. Psychogeriatrics 2024; 24:968-982. [PMID: 38638077 DOI: 10.1111/psyg.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/20/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.
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Affiliation(s)
- Camille Mercier
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Department of Acute Medicine, Clinical Pharmacology and Toxicology Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Mohamed Eshmawey
- Department of Psychiatry, Geriatric Psychiatry Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Aline Mendes
- Geriatrics and Rehabilitation Department, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
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Baptista T, Motuca M, Serrano A, Perez Lo Presti A, Fernandez-Arana A, Olmos I, Pabon A, Yepez JGA, Alejo Galarza GDJ, Rivera Ramirez NM, Elkis H, Sanz EJ, De Las Cuevas C, de Leon J. An expert review of clozapine in Latin American countries: Use, monitoring, and pharmacovigilance. Schizophr Res 2024; 268:60-65. [PMID: 37985318 DOI: 10.1016/j.schres.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Abstract
There is growing interest in clozapine clinical use, monitoring, and research, particularly adverse drug reactions (ADRs) other than agranulocytosis. In this study we focused on clozapine pharmacovigilance. Hence, we contacted clinicians and researchers in Latin America and requested information about local psychiatric services, clozapine availability, clinical use, and ADR monitoring with the VigiBase system. Only two countries have the minimum recommended number of psychiatric beds (15 per 100,000 residents): Uruguay (N = 34.9) and Argentina (N = 17). Bolivia is the only country where clozapine is unavailable. Nine out of twenty countries (45 %) reported ADRs to VigiBase. Argentina, Brazil, Chile, Colombia, and Mexico published national guidelines for schizophrenia treatment. Chile is the sole country with clozapine clinics with drug serum monitoring. Ethnicity-related drug titration in not described in package inserts in any country. We examined in detail the 9 most frequent and important clozapine ADRs in the worldwide database (pneumonia, sudden death, cardiac arrest, agranulocytosis, myocarditis, constipation, arrhythmia, seizure, and syncope). These 9 ADRs led to 294 reports with fatal outcomes in Argentina (N = 3), Brazil (N = 3), Chile (N = 2), and Peru (N = 1). Agranulocytosis was reported from 7 countries: constipation or seizures from 8 countries. Only two countries reported pneumonia and one country reported myocarditis. The number of clozapine reports in VigiBase has no relationship to the country's population. All Latin American countries underreport clozapine associated ADRs. Latin American governments, along with clinicians, researchers, and educators, should optimize clozapine use and monitoring for the benefit of people with severe mental and some neurological disorders.
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Affiliation(s)
- Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela; Medical School, Anáhuac University, Querétaro, Mexico; Neuroorigen, Querétaro, Mexico.
| | - Mariano Motuca
- Department of Psychiatry, School of Medicine at Universidad Nacional de Cuyo, Mendoza, Argentina; Instituto Vilapriño, Centro de Estudios, Asistencia e Investigación en Neurociencias, Mendoza, Argentina
| | - Ana Serrano
- SAMEIN, Salud Mental Integral SAS, Medellin, Colombia
| | | | | | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay; Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Albis Pabon
- Los Andes University Hospital, Psychiatric Unit, Merida, Venezuela
| | - Juan Genaro Ayala Yepez
- Posgrado de Psiquiatría, Facultad de Ciencias Médicas de la Universidad Central del Ecuador, Quito, Ecuador; Centro Ambulatorio especializado San Lázaro, Ministerio de Salud Pública, Quito, Ecuador
| | | | | | - Helio Elkis
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Schulte PFJ. Can clozapine be used for treatment-refractory behavioral and psychological symptoms in dementia patients? Schizophr Res 2024; 268:285-288. [PMID: 37479589 DOI: 10.1016/j.schres.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/08/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands.
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Savva K, Zachariou M, Bourdakou MM, Dietis N, Spyrou GM. D Re Amocracy: A Method to Capitalise on Prior Drug Discovery Efforts to Highlight Candidate Drugs for Repurposing. Int J Mol Sci 2024; 25:5319. [PMID: 38791356 PMCID: PMC11121186 DOI: 10.3390/ijms25105319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
In the area of drug research, several computational drug repurposing studies have highlighted candidate repurposed drugs, as well as clinical trial studies that have tested/are testing drugs in different phases. To the best of our knowledge, the aggregation of the proposed lists of drugs by previous studies has not been extensively exploited towards generating a dynamic reference matrix with enhanced resolution. To fill this knowledge gap, we performed weight-modulated majority voting of the modes of action, initial indications and targeted pathways of the drugs in a well-known repository, namely the Drug Repurposing Hub. Our method, DReAmocracy, exploits this pile of information and creates frequency tables and, finally, a disease suitability score for each drug from the selected library. As a testbed, we applied this method to a group of neurodegenerative diseases (Alzheimer's, Parkinson's, Huntington's disease and Multiple Sclerosis). A super-reference table with drug suitability scores has been created for all four neurodegenerative diseases and can be queried for any drug candidate against them. Top-scored drugs for Alzheimer's Disease include agomelatine, mirtazapine and vortioxetine; for Parkinson's Disease, they include apomorphine, pramipexole and lisuride; for Huntington's, they include chlorpromazine, fluphenazine and perphenazine; and for Multiple Sclerosis, they include zonisamide, disopyramide and priralfimide. Overall, DReAmocracy is a methodology that focuses on leveraging the existing drug-related experimental and/or computational knowledge rather than a predictive model for drug repurposing, offering a quantified aggregation of existing drug discovery results to (1) reveal trends in selected tracks of drug discovery research with increased resolution that includes modes of action, targeted pathways and initial indications for the investigated drugs and (2) score new candidate drugs for repurposing against a selected disease.
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Affiliation(s)
- Kyriaki Savva
- Bioinformatics Department, The Cyprus Institute of Neurology and Genetics, Nicosia 2370, Cyprus; (K.S.); (M.Z.); (M.M.B.)
| | - Margarita Zachariou
- Bioinformatics Department, The Cyprus Institute of Neurology and Genetics, Nicosia 2370, Cyprus; (K.S.); (M.Z.); (M.M.B.)
| | - Marilena M. Bourdakou
- Bioinformatics Department, The Cyprus Institute of Neurology and Genetics, Nicosia 2370, Cyprus; (K.S.); (M.Z.); (M.M.B.)
| | - Nikolas Dietis
- Experimental Pharmacology Laboratory, Medical School, University of Cyprus, Nicosia 2115, Cyprus;
| | - George M. Spyrou
- Bioinformatics Department, The Cyprus Institute of Neurology and Genetics, Nicosia 2370, Cyprus; (K.S.); (M.Z.); (M.M.B.)
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Isop LM, Neculau AE, Necula RD, Kakucs C, Moga MA, Dima L. Metformin: The Winding Path from Understanding Its Molecular Mechanisms to Proving Therapeutic Benefits in Neurodegenerative Disorders. Pharmaceuticals (Basel) 2023; 16:1714. [PMID: 38139841 PMCID: PMC10748332 DOI: 10.3390/ph16121714] [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: 09/12/2023] [Revised: 11/25/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Metformin, a widely prescribed medication for type 2 diabetes, has garnered increasing attention for its potential neuroprotective properties due to the growing demand for treatments for Alzheimer's, Parkinson's, and motor neuron diseases. This review synthesizes experimental and clinical studies on metformin's mechanisms of action and potential therapeutic benefits for neurodegenerative disorders. A comprehensive search of electronic databases, including PubMed, MEDLINE, Embase, and Cochrane library, focused on key phrases such as "metformin", "neuroprotection", and "neurodegenerative diseases", with data up to September 2023. Recent research on metformin's glucoregulatory mechanisms reveals new molecular targets, including the activation of the LKB1-AMPK signaling pathway, which is crucial for chronic administration of metformin. The pleiotropic impact may involve other stress kinases that are acutely activated. The precise role of respiratory chain complexes (I and IV), of the mitochondrial targets, or of the lysosomes in metformin effects remains to be established by further research. Research on extrahepatic targets like the gut and microbiota, as well as its antioxidant and immunomodulatory properties, is crucial for understanding neurodegenerative disorders. Experimental data on animal models shows promising results, but clinical studies are inconclusive. Understanding the molecular targets and mechanisms of its effects could help design clinical trials to explore and, hopefully, prove its therapeutic effects in neurodegenerative conditions.
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Affiliation(s)
- Laura Mihaela Isop
- Department of Fundamental, Prophylactic and Clinical Sciences, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania; (L.M.I.)
| | - Andrea Elena Neculau
- Department of Fundamental, Prophylactic and Clinical Sciences, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania; (L.M.I.)
| | - Radu Dan Necula
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania
| | - Cristian Kakucs
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania
| | - Marius Alexandru Moga
- Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania
| | - Lorena Dima
- Department of Fundamental, Prophylactic and Clinical Sciences, Faculty of Medicine, Transilvania University of Brasov, 500036 Brașov, Romania; (L.M.I.)
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Michael AE, Michael N, Erfurth A, Kujovic M. Clozapine for the treatment of aggressiveness and agitation in advanced dementia. Psychogeriatrics 2023; 23:963-972. [PMID: 37673659 DOI: 10.1111/psyg.13017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/05/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Distressing behavioural symptoms, particularly agitation and aggressiveness, remain a difficult problem in everyday clinical practice in the treatment of multimorbid patients with dementia. Clozapine may be an effective therapeutic alternative in this context. METHODS In a retrospective study, patients who had a diagnosis of dementia and had been treated in a specialized geriatric psychiatry unit with clozapine between August 2018 and February 2022 were included, and medical records were systematically reviewed. The Clinical Global Impressions Scale was used to assess improvement, and the Pittsburgh Agitation Scale for symptom reduction. In addition, side effects and clinical features were documented in detail. RESULTS A total of 31 patients (median age 82 years) were identified with a mean clozapine dose of 47.2 (SD 35.6) mg. A total of 13 patients tolerated clozapine very well, 10 showed tolerable side effects, and in 10 patients side effects were the reason for stopping clozapine. Behavioural symptoms improved significantly, as indicated by the assessment scores. CONCLUSIONS In summary, clozapine was effective and well tolerated in 23 patients, suggesting that low-dose clozapine may help to alleviate the suffering of difficult-to-treat multimorbid patients with advanced dementia and their caregivers. However, particular attention should be paid to adverse drug reactions, especially in patients with cardiovascular and pulmonary impairment.
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Affiliation(s)
- Arwed E Michael
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nikolaus Michael
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Elbroich Hospital, Düsseldorf, Germany
- University of Münster, Münster, Germany
| | - Andreas Erfurth
- University of Münster, Münster, Germany
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Klinik Hietzing, Vienna, Austria
| | - Milenko Kujovic
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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De Las Cuevas C, Sanz EJ, Villasante-Tezanos AG, de Leon J. Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in VigiBase. Expert Opin Drug Metab Toxicol 2023; 19:57-74. [PMID: 36920343 DOI: 10.1080/17425255.2023.2192401] [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: 03/16/2023]
Abstract
INTRODUCTION Antipsychotics (APs), during treatment or overdose, may be associated with respiratory aspiration. AREAS COVERED A PubMed search on September 30, 2022, provided 3 cases of respiratory aspiration during clozapine therapy and 1 case during an AP overdose. VigiBase records of respiratory aspiration associated with APs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC). EXPERT OPINION The ICs (and IC025) were 2.1 (and 2.0) for APs, 3.2 (and 3.0) for clozapine, 2.6 (and 2.4) for quetiapine, and 2.5 (and 2.2) for olanzapine. Cases of respiratory aspiration associated with APs included: 137 overdose/suicide cases (64 fatal) and 609 cases during treatment (385 fatal) including 333 taking clozapine (238 fatal). In logistic regression models of fatal outcomes, the odds ratios, OR, and (95% confidence intervals, CI) of significant independent variables were: a) 2.3 - 2.6 for clozapine in 3 samples of AP treatment of varying size, b) 1.9 (CI 1.0 to 3.5) for geriatric age in 284 patients on clozapine treatment, and c) 1.8 (CI 1.1 - 3.2) for antidepressant co-medication in 276 patients on non-clozapine APs. Multiple AP pharmacological mechanisms may explain respiratory aspiration.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain.,Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Alejandro G Villasante-Tezanos
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, United States
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, United States.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Andreea T, Petru I, Miron AA, Paula-Simina P, Lorena D. Clozapine for Treatment-Refractory Aggressive Behavior. Psychiatr Q 2021; 92:721-733. [PMID: 32918660 DOI: 10.1007/s11126-020-09839-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 01/17/2023]
Abstract
Emergency psychiatry has the main role of resolving suicidal behavior and aggression. These severe psychiatric symptoms can be found in many psychiatric disorders such as schizophrenia, bipolar disorder, major depression, personality disorders, cognitive disorders, intellectual disability and substance abuse. Although indications for the use of antipsychotics are limited to a specific group of diseases, they are frequently used as rescue medication in high-risk or nonresponsive cases. Clozapine, the gold standard for TRS (treatment resistant schizophrenia) is effective in controlling aggression. The aim of the research was to identify the use of clozapine for treatment-refractory aggressive behavior in psychiatric emergency. A retrospective study based on the paper files of patients admitted between 2010 and 2019 in the Clinical Hospital of Psychiatry and Neurology of Brasov, Romania. Were included all the patients admitted as a psychiatric emergency and treated with clozapine for aggressive behavior. The hospital is an academic institution with 150 beds for acute patients, serving an area of over 600,000 inhabitants. It is the main public institution where patients with psychiatric emergencies are hospitalized. Off 19,000 patients admitted during the study period, 504 patients (2,4%) with a diagnosis other than schizophrenia or schizoaffective disorder received clozapine for aggressiveness (89.5%). The first four diagnoses identified were bipolar disorder (n = 172), intellectual disability (n = 128), cognitive impairment (n = 112), and personality disorder (n = 92). Other disorders identified but with a smaller number of cases were major depressive disorder (n = 3), adjustment disorders (n = 2), delusional disorder (n = 2), obsessive compulsive disorder (n = 2) and postpartum psychosis (n = 1). Clozapine was used as 3rd or 4th choice. The dose was greater for manic patients (350.29 ± 98.01 mg/day) compared with all the other diagnoses. Clozapine was effective and safe in cases of patients with treatment-refractory aggressive behavior.
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Affiliation(s)
- Teodorescu Andreea
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Ifteni Petru
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania.
| | - Ana Aliana Miron
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Petric Paula-Simina
- 1st and 3rd Clinical Departments, Clinical Hospital of Psychiatry and Neurology of Brasov, Brasov, Romania
| | - Dima Lorena
- Faculty of Medicine, Transilvania University of Brasov, 56 Nicolae Bălcescu Str., 500019, Brasov, Romania
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Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:brainsci10110840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background: clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. Objective: to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. Data sources: a search was performed in two databases (PubMed and Web of Science) using the specific keywords “clozapine” and “schizophrenia”, “side effects”, “agranulocytosis”, “TRS”, or “bipolar affective disorder (BAF)” for the last ten years. Study eligibility criteria: clinical trials on adults with acute symptoms of schizophrenia or related disorders. Results: we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. Limitations: we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions’ severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Abstract
BACKGROUND Psychotic episodes in the postpartum period are life-threatening psychiatric emergencies, requiring urgent medical attention and admission to a psychiatric hospital. AREAS OF UNCERTAINTY Although the postpartum psychosis (PPP) is the most severe psychiatric disorder associated with parturition, there is little information about what interventions are most effective. Because there are no specific guidelines for the treatment of PPP, the aim of the present review was to examine the available evidence regarding the treatment of PPP. DATA SOURCES The PubMed database was searched based on the title and the abstract, using the key words "postpartum psychosis," "postpartum psychosis antipsychotics," "postpartum psychosis treatment," and "postpartum psychosis pharmacotherapy," for both interventional and observational, irrespective of language. RESULTS A number of 14 publications met the study criteria, including case reports and case series. The antipsychotics (APs) use included both first generation APs, such as haloperidol and chlorpromazine, and second generation APs, mainly, olanzapine, quetiapine, and risperidone. The most frequently used AP was olanzapine. Olanzapine and quetiapine seem to be the most acceptable during breastfeeding. Proposed treatment algorithms for the successful management of PPP are discussed. CONCLUSIONS The existing studies to date do not allow to draw a definitive conclusion regarding which treatment is the most effective or the most adequate. Existing evidence suggests that APs alone or in combination are responsible for sustained remission and that treated PPP has a higher pace of improvement of the mental status, with a rapid discharge from the hospital. Clinical studies to compare the efficacy and safety of different APs in the PPP are needed to provide guidance on treatment interventions.
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A Systematic Review of Clinical Studies on the Effect of Psychoactive Cannabinoids in Psychiatric Conditions in Alzheimer Dementia. Am J Ther 2020; 27:e249-e269. [DOI: 10.1097/mjt.0000000000001120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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