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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024; 23:811-831. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Lorini Franciscatto I, Scherer Seibert B, Dries SS, Linden R, Ziulkoski AL, Perassolo MS. Evaluation of oxidative stress and its association with drug therapy in inpatients treated for cocaine dependence. Drug Chem Toxicol 2024; 47:372-380. [PMID: 37259499 DOI: 10.1080/01480545.2023.2219039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/22/2023] [Indexed: 06/02/2023]
Abstract
The use of cocaine affects several systems and organs of the human body and the consumption of this substance leads to an increase in the production of reactive oxygen species, and to the reduction of antioxidant defenses. The aim of this study was to evaluate the oxidative stress (OS), biochemical and hematological parameters in patients hospitalized for treatment of cocaine addiction, comparing levels at hospital admission and discharge. Forty patients were included in the study. OS was evaluated using catalase (CAT), superoxide dismutase (SOD), glutathione reductase (GPx), total antioxidant power (FRAP), malondialdehyde (MDA), and sulfhydryl group (GS). The medications used during hospitalization were registered and their influence on the parameters of OS was analyzed. After the hospitalization period, there was an increase in GGT levels, a reduction in SOD activity, and an increase in GPx activity and FRAP levels. Carbamazepine users had higher SOD values and lower FRAP values at hospital discharge. The use of chlorpromazine caused differences in creatinine and gamma-glutamyltransferase (GGT) serum leves, and the levels of glutamic oxalacetic transaminase (TGO), MDA, and FRAP were increased at hospital discharge. Haloperidol and thiamine during hospitalization interfered with alkaline phosphatase levels. The use of risperidone caused an increase in the levels of SOD, and folic acid use was associated with lower levels of GPx and higher levels of glutamic-pyruvic transaminase (TGP) and alkaline phosphatase. Drug rehabilitation treatment was effective in decreasing oxidative damage represented by the reduction of biological markers.
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Affiliation(s)
- Isabela Lorini Franciscatto
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- University Pharmacy, Feevale University, Novo Hamburgo, RS, Brazil
| | - Bruna Scherer Seibert
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- University Pharmacy, Feevale University, Novo Hamburgo, RS, Brazil
| | - Samuel Selbach Dries
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- University Pharmacy, Feevale University, Novo Hamburgo, RS, Brazil
| | - Rafael Linden
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- Laboratory of Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil
| | - Ana Luiza Ziulkoski
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- Molecular Microbiology Laboratory, Feevale University, Novo Hamburgo, Brazil
| | - Magda Susana Perassolo
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, RS, Brazil
- University Pharmacy, Feevale University, Novo Hamburgo, RS, Brazil
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Serretti A. Stroke, COVID-19, and other somatic aspects of psychiatric disorders treatments. Int Clin Psychopharmacol 2024; 39:123-126. [PMID: 38527157 DOI: 10.1097/yic.0000000000000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
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Ali E, Abdel Maksoud MA, Arafa SM, Ibrahim D, Hassan AES, Awwad O, Elbeltagy AM, Elmahdi E, Elgarhi R, Embaby A. Elevated liver transaminases among patients with psychiatric disorders. Int Clin Psychopharmacol 2024; 39:195-200. [PMID: 37781786 DOI: 10.1097/yic.0000000000000514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Hepatocyte injury is assessed by serum aspartate transaminase and alanine transaminase estimation. In psychiatric populations, antipsychotic drugs (AD) are culprit in hepatic dysfunction. To assess transaminitis among psychiatric patients treated by AD. This cross-sectional study was conducted in Zagazig University Hospitals in Egypt, from December 2022 to February 2023. A total of 135 adult patients aged ≥ 18 years, were diagnosed with psychiatric disorders after exclusion of patients receiving any hepatotoxic drugs, viral hepatitis, having chronic liver or kidney diseases, diabetes mellitus, mental retardation, and pregnant females. Among the 135 patients, 104 (77.0%) were males. Their age was 32 ± 9, The most popular used class of AD was atypical AD 84 (62.2%). The overall incidence of transaminitis among patients receiving AD was 23/135 (17.04%) of patients; 13 (56.5%) were on atypical AD compared to 10 (43.5%) patients receiving combined AD, without any statistically significant difference. The use of AD in patients with psychiatric disorders is potentially safe with minimal transaminitis (
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Affiliation(s)
- Eman Ali
- Psychiatry Department, Faculty of Medicine, Zagazig University
| | | | - Shaymaa M Arafa
- Psychiatry Department, Faculty of Medicine, AlAzhar University for Girls, Cairo
| | - Doaa Ibrahim
- Psychiatry Department, Faculty of Medicine, AlAzhar University for Girls, Cairo
| | - Ahmed El-Sayed Hassan
- Medical Physiology Department, Faculty of Medicine, Zagazig University
- Basic Medical Sciences Department, Faculty of Medicine, Sulaiman Al Rajhi University, Al-Bukayriyah, Saudi Arabia
| | - Omnia Awwad
- Family Medicine and Health Informatics Specialist at Ministry of Health and Population, Zagazig
| | - Ahmed M Elbeltagy
- Clinical Pathology Department, Faculty of Medicine, Mansoura University
| | - Essam Elmahdi
- Internal Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Internal Medicine Department, Faculty of Medicine, Shaqra University, Dawadmi, Saudi Arabia
| | - Reham Elgarhi
- Clinical Pharmacology Department, Faculty of Medicine, Zagazig University
| | - Ahmed Embaby
- Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Atolagbe A, Nkemjika S. Remission of Clozapine-Induced Hepatotoxicity Following a Switch to Olanzapine Augmented with Haloperidol: A Case Report and Literature Review. Cureus 2024; 16:e57341. [PMID: 38690462 PMCID: PMC11060696 DOI: 10.7759/cureus.57341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/02/2024] Open
Abstract
Clozapine is an effective medication for treatment-resistant schizophrenia, and it has been associated with well-documented side effects that limit its use. Clozapine-induced hepatotoxicity is a less-known complication of clozapine therapy. The literature is unclear about the psychopharmacologic options available following clozapine cessation on account of liver toxicity. We present a patient with clinical symptomatology in keeping with clozapine-induced hepatotoxicity who achieved full recovery following clozapine cessation and conservative medical management. Her psychiatric symptomatology was successfully managed with oral olanzapine augmented with haloperidol without recurrence of psychosis or liver toxicity.
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Affiliation(s)
- Ayodele Atolagbe
- Psychiatry and Behavioral Sciences, Kingsbrook Jewish Medical Center, Brooklyn, USA
| | - Stanley Nkemjika
- Population Health Sciences, Georgia State University School of Public Health, Atlanta, USA
- Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, USA
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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity induced by clozapine: Case report and brief review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2023; 52:165-170. [PMID: 37460343 DOI: 10.1016/j.rcpeng.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/21/2021] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru
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Soares MA, Costa ALA, Silva NLC, Martins AF, Matias DO, Araujo OMO, Lopes RT, Takiya CM, Miranda ALP, Miranda-Alves L, Tributino JLM. Atypical antipsychotics olanzapine and clozapine increase bone loss in female rats with experimental periodontitis. J Periodontal Res 2023; 58:283-295. [PMID: 36575324 DOI: 10.1111/jre.13090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/01/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Periodontitis is a highly prevalent disease in psychiatric patients, including those undergoing symptomatic treatment with second-generation antipsychotics. Some of these drugs, such as clozapine (CLO) and olanzapine (OLA), have prominent metabolic effects such as weight gain, hyperglycemia, and dyslipidemia, which are risk factors for periodontitis. In addition to the metabolic effects, there are reports of changes in salivary flow, gingival bleeding, and caries. In this context, we aimed to evaluate if the metabolic effects of OLA and CLO alter periodontal parameters in an animal model of periodontitis without the environmental and psychosocial biases inherent to human diseases. METHODS In the first set of experiments, male and female adult Wistar rats received oral administration of CLO, OLA, or vehicle for 45 days. They were evaluated for body mass composition and weight gain, blood glucose parameters (fasting and glucose tolerance and insulin resistance tests), and lipid profile (HDL, total cholesterol, and triglycerides). In a second set of experiments, the same measurements were performed in female rats exposed to the antipsychotics for 45 days and ligature-induced periodontitis on the 30th day of treatment. Macroscopic measurements of exposed roots, microtomography in the furcation region of the first molar, and histological evaluation of the region between the first and second molars were evaluated to assess bone loss. Additionally, gingival measurements of myeloperoxidase activity and pro-inflammatory cytokine TNF-α were made. RESULTS Only females exposed to OLA had more significant weight gain than controls. They also exhibited differences in glucose metabolism. Ligature-induced periodontitis produced intense bone retraction without changing the density of the remaining structures. The bone loss was even higher in rats with periodontitis treated with OLA or CLO and was accompanied by a local increase in TNF-α caused by CLO. These animals, however, did not exhibit the same metabolic impairments observed for animals without periodontitis. CONCLUSION The use of clozapine and olanzapine may be a risk factor for periodontal disease, independent of systemic metabolic alterations.
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Affiliation(s)
- Mariana Alves Soares
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Programa de Pós-Graduação em Farmacologia e Química Medicinal, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - André Luiz A Costa
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Natália L C Silva
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline França Martins
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daiane Oliveira Matias
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Olga M O Araujo
- Laboratório de Instrumentação Nuclear (LIN), Programa de Engenharia Nuclear (PEN), Instituto Alberto Luiz de Coimbra de Pós-Graduação e Pesquisa de Engenharia (COPPE-UFRJ), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ricardo Tadeu Lopes
- Laboratório de Instrumentação Nuclear (LIN), Programa de Engenharia Nuclear (PEN), Instituto Alberto Luiz de Coimbra de Pós-Graduação e Pesquisa de Engenharia (COPPE-UFRJ), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christina Maeda Takiya
- Laboratório de Patologia Celular, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Luisa P Miranda
- Laboratório de Estudos em Farmacologia Experimental (LEFEx), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Miranda-Alves
- Laboratório de Endocrinologia Experimental (LEEx), Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge L M Tributino
- Laboratório de Farmacologia Molecular (LFM), Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Gunther M, Dopheide JA. Antipsychotic Safety in Liver Disease: A Narrative Review and Practical Guide for the Clinician. J Acad Consult Liaison Psychiatry 2023; 64:73-82. [PMID: 36180017 DOI: 10.1016/j.jaclp.2022.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinicians treating psychiatric disorders in medically ill patients need a comprehensive resource for comparing the risk and types of liver injury associated with antipsychotic therapy. OBJECTIVE We conducted a narrative review aimed at developing a comprehensive resource comparing antipsychotics with regard to risk of inducing or worsening liver injuries, types of liver injury, associated pharmacokinetic changes, dosing, monitoring, and patient counseling recommendations. METHODS We conducted database searches of LiverTox.nih.gov, DailyMed.nlm.nih.gov, and PubMed through June of 2022. Sources describing premarketing data, observational studies, case reports and case series of antipsychotic-induced liver injuries, types of hepatic dysfunction, interventions, recovery, and treatment for 15 antipsychotics were included. Duplicate reports were excluded. Antipsychotics were graded as low, low to moderate, moderate, moderate to high, or high risk for causing or worsening a liver disease. RESULTS Of the 1861 publications, 21 papers met criteria and were included. Evidence shows antipsychotic-induced liver dysfunction is uncommon to rare. Chlorpromazine, clozapine, and olanzapine pose the greatest risk of hepatoxicity; quetiapine and risperidone pose a moderate risk with haloperidol considered to pose low to moderate risk. Paliperidone, aripiprazole, lurasidone, and loxapine are lower-risk agents with no reports of liver failure. Transaminitis that is mild and self-limiting is the most common antipsychotic-induced liver injury followed by hepatocellular disease, steatosis, and mixed liver injury. A careful risk-benefit analysis should guide the decision to discontinue the antipsychotic in cases of severe liver disease. Dose adjustments and careful monitoring are recommended for a mild to moderate disease when the benefits of treating psychosis outweigh the risks. Patients without an existing liver disease initiating a treatment with a higher-risk antipsychotic should be counseled to report symptoms of liver injuries along with regular lab monitoring. CONCLUSIONS Antipsychotic selection, dosing, monitoring, and counseling should be individualized based on whether a patient has an existing liver disease and if they are receiving an agent that poses a higher risk of liver injury. The consultation-liaison psychiatry provider can guide the primary team in management through thoughtful integration of the known pathophysiologic changes in hepatic disease and risk-benefit analysis of antipsychotic safety profiles.
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Affiliation(s)
- Matthew Gunther
- LAC+USC Medical Center, Los Angeles, CA; Keck School of Medicine, Department of Psychiatry, University of Southern California, Los Angeles, CA.
| | - Julie A Dopheide
- LAC+USC Medical Center, Los Angeles, CA; Keck School of Medicine, Department of Psychiatry, University of Southern California, Los Angeles, CA; USC School of Pharmacy, University of Southern California, Los Angeles, CA
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When to Use Amisulpride in Adolescents: A Retrospective Chart Examination of Inpatients. J Clin Psychopharmacol 2022; 42:247-253. [PMID: 35149609 DOI: 10.1097/jcp.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/BACKGROUND Despite increasing interest in amisulpride, current knowledge about its use in the pediatric population is scarce. This chart review aimed to investigate the use of amisulpride in a naturalistic adolescent population. METHODS/PROCEDURES Electronic medical records of a tertiary care adolescent inpatient unit were screened between January 2015 and April 2021. Sociodemographic data and all clinical information were collected via data collection forms, and targeted symptoms were obtained from patients' files. Patients with early-onset psychotic disorders (n = 58), bipolar I disorder (n = 29), major depressive disorder (n = 14), and other psychiatric diagnoses (n = 9) were included. Treatment response was defined as a Clinical Global Impression-Improvement of at least much improvement after treatment. FINDINGS/RESULTS Median titration rate of amisulpride was 400 mg/wk, and the maximum administered daily dose ranged between 100 and 1200 mg/d. The maximum daily dose and number of previous antipsychotics were higher in the early-onset psychotic disorder group. Persistent positive symptoms and resistance to previous treatments were leading causes for amisulpride treatment. Other indications were also impulsive/disruptive behaviors, antipsychotic adverse effects, depressive symptoms, somatic complaints, and abnormalities in liver function tests. Finally, patients with lower daily treatment doses and more previous antipsychotic trials are less likely to benefit from the treatment. IMPLICATIONS/CONCLUSIONS Persistent psychotic/mood symptoms, impulsive/disruptive behaviors, and abnormalities in liver function tests were reasons for the amisulpride treatment in adolescents. Randomized placebo-controlled trials are needed to evaluate the efficacy and safety of the treatment in adolescents.
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Menon V, Ransing R, Praharaj SK. Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases. Indian J Psychiatry 2022; 64:S379-S393. [PMID: 35602369 PMCID: PMC9122174 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramdas Ransing
- Department of Psychiatry, BKL Walalwalkar Rural Medical College, Ratnagiri, Maharashtra, India
| | - Samir Kumar Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India E-mail:
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Yi W, Ji Y, Gao H, Pan R, Wei Q, Cheng J, Song J, He Y, Tang C, Liu X, Song S, Su H. Does the gut microbiome partially mediate the impact of air pollutants exposure on liver function? Evidence based on schizophrenia patients. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 291:118135. [PMID: 34534831 DOI: 10.1016/j.envpol.2021.118135] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 06/13/2023]
Abstract
Air pollution may alter the composition of gut microbiome and subsequent liver-related metabolic disorders. Schizophrenia was often accompanied by liver dysfunction. But it was still unclear whether air pollutants affected liver function in patients with schizophrenia through gut microbiome. We aimed to clarify the impacts of long-term air pollutants on the gut microbiome and liver function in schizophrenia and to evaluate the intermediary effect of microbiome. Schizophrenia patients were recruited then serum biochemical indicators were tested. Air pollutant exposure in the previous year was retrospectively estimated by inverse distance weighting. The associations among air pollutants, gut microbiome, and liver function indicators in schizophrenia were estimated. Then the mediating effect of gut microbiome was further explored. The results showed that nitrogen dioxide (NO2), carbonic oxide (CO), ozone (O3), particulate matter with aerodynamic diameter ≤10 μm (PM10), and fine particulate matter (PM2.5) explained 2.68%-10.77% of the variation in gut microbiome composition (order level) in schizophrenia (all P < 0.05). Network correlation analysis indicated that air pollutants and liver function indicators were mainly related to Firmicutes, Actinobacteria, and Proteobacteria in schizophrenia. Long-term NO2 exposure significantly increased the levels of gamma-glutamyl transpeptidase (GGT) and glutamic pyruvic transaminase (GPT) in schizophrenia. Coriobacteriales mediated 13.98% and 49.56% (all P < 0.05) of the associations of long-term NO2 with GGT and GPT, respectively. To conclude, long-term NO2 exposure is positively associated with liver dysfunction in schizophrenia, in which gut microbiome plays an intermediary role. The two pathways, "NO2-Coriobacteriales-GGT" and "NO2-Coriobacteriales-GPT", would provide scientific evidence for the intervention of schizophrenia with liver dysfunction.
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Affiliation(s)
- Weizhuo Yi
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Yifu Ji
- Anhui Mental Health Center, Hefei, Anhui, China
| | - Hua Gao
- Anhui Mental Health Center, Hefei, Anhui, China
| | - Rubing Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Qiannan Wei
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Jian Cheng
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Jian Song
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Yangyang He
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Chao Tang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Xiangguo Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Shasha Song
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China
| | - Hong Su
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, China.
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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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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity Induced by Clozapine: Case Report and Brief Review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 52:S0034-7450(21)00087-1. [PMID: 34167791 DOI: 10.1016/j.rcp.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/22/2020] [Accepted: 04/21/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú
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14
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Druschky K, Toto S, Bleich S, Baumgärtner J, Engel RR, Grohmann R, Maier HB, Neyazi A, Rudolph YJ, Rüther E, Schwörer H, Seifert J, Stübner S, Degner D. Severe drug-induced liver injury in patients under treatment with antipsychotic drugs: Data from the AMSP study. World J Biol Psychiatry 2021; 22:373-386. [PMID: 32892689 DOI: 10.1080/15622975.2020.1819565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Drug-induced liver injury (DILI) has been associated with various antipsychotic drugs (APDs). Comparative studies between individual APDs are largely not available. METHODS Antipsychotic drug utilisation data and reports of severe antipsychotic DILI were assessed by using data from an observational pharmacovigilance programme-Arzneimittelsicherheit in der Psychiatrie (AMSP)-during the period 1993-2016. RESULTS Of the 333,175 patients treated with APDs, a total of 246 (0.07%) events of severe DILI were identified. Phenothiazines were associated with significantly higher rates of severe DILI (0.03%, 95% CI = 0.02-0.04) than thioxanthenes (0.01%, 95% CI = 0.00-0.02) or butyrophenones (0.01%, 95% CI = 0.00-0.01). Among individual drugs, olanzapine (0.12%, 95% CI = 0.10-0.16), perazine (0.09%, 95% CI = 0.05-0.15) and clozapine (0.09%, 95% CI = 0.10-0.12 ranked highest. In 78 cases (31.7%), combination therapies with antipsychotic and antidepressant drugs or with two or more APDs were considered responsible. Male sex and a diagnosis of mania were associated with significantly higher rates of severe DILI while older patients (≥65 years old) were significantly less often affected. CONCLUSIONS In the present analysis of a representative psychiatric inpatient cohort, olanzapine, perazine, and clozapine were the most common individual APDs associated with severe DILI.
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Affiliation(s)
- Katrin Druschky
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Augsburg, Germany
| | - Rolf R Engel
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Yannick J Rudolph
- Department of Psychiatry and Psychotherapy, Georg-August University of Goettingen, Goettingen, Germany
| | - Eckart Rüther
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Harald Schwörer
- Department of Gastroenterology and Gastrointestinal Oncology, Liver Center Goettingen, University Medical Center Goettingen, Georg-August University of Goettingen, Göttingen, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Susanne Stübner
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany.,Department of Forensic Psychiatry, Kbo-IAK, Academic Teaching Hospital of the Ludwig-Maximilian University, Munich, Germany
| | - Detlef Degner
- Department of Psychiatry and Psychotherapy, Georg-August University of Goettingen, Goettingen, Germany
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17
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Koller D, Almenara S, Mejía G, Saiz-Rodríguez M, Zubiaur P, Román M, Ochoa D, Navares-Gómez M, Santos-Molina E, Pintos-Sánchez E, Abad-Santos F. Metabolic Effects of Aripiprazole and Olanzapine Multiple-Dose Treatment in a Randomised Crossover Clinical Trial in Healthy Volunteers: Association with Pharmacogenetics. Adv Ther 2021; 38:1035-1054. [PMID: 33278020 PMCID: PMC7889573 DOI: 10.1007/s12325-020-01566-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/07/2020] [Indexed: 12/11/2022]
Abstract
Introduction Aripiprazole and olanzapine are atypical antipsychotics. Both drugs can induce metabolic changes; however, the metabolic side effects produced by aripiprazole are more benign. The aim of the study was to evaluate if aripiprazole and olanzapine alter prolactin levels, lipid and glucose metabolism and hepatic, haematological, thyroid and renal function. Methods Twenty-four healthy volunteers received a daily oral dose of 10 mg aripiprazole and 5 mg olanzapine tablets for 5 days in a crossover randomised clinical trial and were genotyped for 51 polymorphisms in 18 genes by qPCR. Drug plasma concentrations were measured by LC–MS. The biochemical and haematological analyses were performed by enzymatic methods. Results Olanzapine induced hyperprolactinaemia but aripiprazole did not. Dopamine D3 receptor (DRD3) Ser/Gly and ATP binding cassette subfamily B member 1 (ABCB1) rs10280101, rs12720067 and rs11983225 polymorphisms and cytochrome P450 3A (CYP3A) phenotype had an impact on plasma prolactin levels. C-peptide concentrations were higher after aripiprazole administration and were influenced by catechol-O-methyltransferase (COMT) rs4680 and rs13306278 polymorphisms. Olanzapine and the UDP glucuronosyltransferase family 1 member A1 (UGT1A1) rs887829 polymorphism were associated with elevated glucose levels. CYP3A poor metabolizers had increased insulin levels. Volunteers’ weight decreased significantly during aripiprazole treatment and a tendency for weight gain was observed during olanzapine treatment. Triglyceride concentrations decreased as a result of olanzapine and aripiprazole treatment, and varied on the basis of CYP3A phenotypes and the apolipoprotein C-III (APOC3) rs4520 genotype. Cholesterol levels were also decreased and depended on 5-hydroxytryptamine receptor 2A (HTR2A) rs6314 polymorphism. All hepatic enzymes, platelet and albumin levels, and prothrombin time were altered during both treatments. Additionally, olanzapine reduced the leucocyte count, aripiprazole increased free T4 and both decreased uric acid concentrations. Conclusions Short-term treatment with aripiprazole and olanzapine had a significant influence on the metabolic parameters. However, it seems that aripiprazole provokes less severe metabolic changes. Trial Registration Clinical trial registration number (EUDRA-CT): 2018-000744-26 Graphical Abstract ![]()
Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01566-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dora Koller
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Susana Almenara
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Gina Mejía
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Miriam Saiz-Rodríguez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- Research Unit, Fundación Burgos Por La Investigación de La Salud, Hospital Universitario de Burgos, Burgos, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Manuel Román
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Dolores Ochoa
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Marcos Navares-Gómez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Elena Santos-Molina
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Elena Pintos-Sánchez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, School of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain.
- UICEC Hospital Universitario de La Princesa, Platform SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain.
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Khorassani F, Sousonis F, Lopez LV. Risperidone- and paliperidone-induced hepatotoxicity: Case report and review of literature. Am J Health Syst Pharm 2020; 77:1578-1584. [DOI: 10.1093/ajhp/zxaa224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Purpose
A case of hepatotoxicity likely due to use of risperidone and paliperidone is reported.
Summary
A 23-year-old man with schizophrenia was admitted to an inpatient psychiatric unit after an exacerbation of mental illness secondary to medication nonadherence. During 13 days of treatment with risperidone, the patient’s liver enzyme levels rose sharply, so antipsychotic therapy was switched to oral paliperidone. After a 5-day downward trend in liver enzyme levels, a dose of intramuscular paliperidone was administered to augment oral paliperidone therapy. After 10 days of paliperidone use, abnormally high liver enzyme levels were again noted; both oral and intramuscular paliperidone therapy were discontinued and haloperidol was initiated, with complete resolution of liver enzyme abnormalities within approximately 4 weeks. Scoring of this case using the algorithm of Naranjo et al indicated probable associations between risperidone use and hepatotoxicity (a score of 7) and paliperidone use and hepatotoxicity (a score of 8). To our knowledge, this is the first case report describing a patient who developed hepatotoxicity during risperidone use that did not remit with a switch to paliperidone therapy.
Conclusion
Findings of this case suggest that patients who develop hepatotoxicity with use of risperidone may also do so with paliperidone use; this, in turn, suggests that both risperidone and its metabolite are capable of causing hepatotoxicity. Patients who develop hepatotoxicity in response to risperidone or paliperidone therapy may benefit from treatment with an alternative antipsychotic with a different chemical structure.
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Affiliation(s)
- Farah Khorassani
- Department of Clinical Health Professions, St. John’s University College of Pharmacy and Health Sciences, Queens, NY, and Department of Pharmacy, Bellevue Hospital Center, New York, NY
| | - Frances Sousonis
- College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, and Bristol-Myers Squibb, Lawrenceville, NJ
| | - Leonardo V Lopez
- Department of Psychiatry, Bellevue Hospital Center, New York, NY, and Department of Psychiatry, NYU School of Medicine, New York, NY
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Dries SS, Seibert BS, Bastiani MF, Linden R, Perassolo MS. Evaluation of oxidative stress biomarkers and liver and renal functional parameters in patients during treatment a mental health unit to treat alcohol dependence. Drug Chem Toxicol 2020; 45:861-867. [PMID: 32567384 DOI: 10.1080/01480545.2020.1780251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Alcohol dependence is one of the main reasons for inpatient admission to psychiatric hospitals. The abuse of this chemical substance can cause modifications in our organism and among them, variations in the oxidative stress parameters. Therefore, the aim of this study is to evaluate patients admitted to a psychiatric hospital unit to treat alcohol dependence, comparing oxidative stress, renal and hepatic function parameters from the moment of admission to those obtained at discharge. Hepatic function was verified through gamma-glutamyl-transferase (GGT), alkaline-phosphatase (ALP), aspartate-aminotransferase (AST) and alanine-aminotransferase (ALT) activity measurements. Urea and creatinine serum levels were measured for kidney function evaluation. Oxidative stress was evaluated by superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), ferric reducing antioxidant power (FRAP) and malondialdehyde (MDA). Medications used during hospital stay were record and their influence over the measured parameters analyzed. Twenty-eight patients (82% male, 44 ± 13 years old) were included in this study. A significant increase in BMI of patients after the period of hospitalization could be observed. There were reductions in creatinine, AST, ALT, GGT and ALP serum levels. SOD levels were lower at discharge, while GPx and FRAP presented higher levels. Chlorpromazine use showed influence over some hepatic function markers (ALT, GGT and ALP) and oxidative stress parameters (CAT and GPx); while carbamazepine use influenced GGT and FRAP. Patients on alcohol dependence treatment had significant improvements of renal and hepatic function parameters and higher GPx and FRAP values after the hospitalization period, which indicates reversion of alcohol effects over oxidative stress parameters.
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Affiliation(s)
- Samuel Selbach Dries
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil.,University Pharmacy, Feevale University, Novo Hamburgo, Brazil
| | | | - Marcos Frank Bastiani
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil.,Laboratory of Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil
| | - Rafael Linden
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil.,Laboratory of Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil
| | - Magda Susana Perassolo
- Graduate Program on Toxicology and Analytical Toxicology, Feevale University, Novo Hamburgo, Brazil.,University Pharmacy, Feevale University, Novo Hamburgo, Brazil
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20
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Taylor RW, Marwood L, Oprea E, DeAngel V, Mather S, Valentini B, Zahn R, Young AH, Cleare AJ. Pharmacological Augmentation in Unipolar Depression: A Guide to the Guidelines. Int J Neuropsychopharmacol 2020; 23:587-625. [PMID: 32402075 PMCID: PMC7710919 DOI: 10.1093/ijnp/pyaa033] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/27/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pharmacological augmentation is a recommended strategy for patients with treatment-resistant depression. A range of guidelines provide advice on treatment selection, prescription, monitoring and discontinuation, but variation in the content and quality of guidelines may limit the provision of objective, evidence-based care. This is of importance given the side effect burden and poorer long-term outcomes associated with polypharmacy and treatment-resistant depression. This review provides a definitive overview of pharmacological augmentation recommendations by assessing the quality of guidelines for depression and comparing the recommendations made. METHODS A systematic literature search identified current treatment guidelines for depression published in English. Guidelines were quality assessed using the Appraisal of Guidelines for Research and Evaluation II tool. Data relating to the prescription of pharmacological augmenters were extracted from those developed with sufficient rigor, and the included recommendations compared. RESULTS Total of 1696 records were identified, 19 guidelines were assessed for quality, and 10 were included. Guidelines differed in their quality, the stage at which augmentation was recommended, the agents included, and the evidence base cited. Lithium and atypical antipsychotics were recommended by all 10, though the specific advice was not consistent. Of the 15 augmenters identified, no others were universally recommended. CONCLUSIONS This review provides a comprehensive overview of current pharmacological augmentation recommendations for major depression and will support clinicians in selecting appropriate treatment guidance. Although some variation can be accounted for by date of guideline publication, and limited evidence from clinical trials, there is a clear need for greater consistency across guidelines to ensure patients receive consistent evidence-based care.
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Affiliation(s)
- Rachael W Taylor
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Lindsey Marwood
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,Correspondence: Lindsey Marwood, PhD, 103 Denmark Hill, PO74, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE58AF, United Kingdom ()
| | - Emanuella Oprea
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Valeria DeAngel
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Sarah Mather
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Beatrice Valentini
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,Department of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Roland Zahn
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Allan H Young
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Anthony J Cleare
- The Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom,National Institute for Health Research Maudsley Biomedical Research Centre, South London & Maudsley NHS Foundation Trust, London, United Kingdom
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21
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Cinar I, Halici Z, Dincer B, Sirin B, Cadirci E. The role of 5-HT7 receptors on isoproterenol-induced myocardial infarction in rats with high-fat diet exacerbated coronary endothelial dysfunction. Hum Exp Toxicol 2020; 39:1005-1018. [PMID: 32329363 DOI: 10.1177/0960327120916821] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The presence of 5-HT7r's in both human and rat cardiovascular and immune tissues and their contribution to inflammatory conditions prompted us to hypothesize that these receptors contribute in acute myocardial infarction (MI) with underlying chronic endothelial dysfunction. We investigated the role of 5-HT7 receptors on heart tissue that damaged by isoproterenol (ISO)-induced MI in rats with high-fat diet (HFD). In vitro and in vivo effects of 5-HT7r agonist (LP44) and antagonist (SB269970) have been investigated on the H9C2 cell line and rats, respectively. For in vivo analyses, rats were fed with HFD for 8 weeks and after this period ISO-induced MI model has been applied to rat. To investigate the role of 5-HT7r's, two different doses of LP44 and SB269970 were evaluated and compared with standard hypolipidemic agent, atorvastatin. In vitro studies showed that LP44 has protective and proliferative effects on rat cardiomyocytes. Also in in vivo studies stimulating 5-HT7r's by LP44 improved blood lipid profile (decreased total cholesterol, low-density lipoprotein-C, and triglyceride, increased high-density lipoprotein), decreased cardiac damage markers (creatine kinase and troponin-I), and corrected inflammatory status (tumor necrosis factor-α, interleukin-6). Our results showed significant improvement in LP44 administered rats in terms of histopathologic analyses. In damaged tissues, 5-HT7 mRNA expression increased and agonist administration decreased this elevation significantly. We determined for the first time that 5-HT7r's are overexpressed in ISO-induced MI of rats with underlying HFD-induced endothelial dysfunction. Restoration of this overexpression by LP44, a 5-HT7r agonist, ameliorated heart tissue in physiopathologic, enzymatic, and molecular level, showing the cardiac role of these receptors and suggesting them as future potential therapeutic targets.
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Affiliation(s)
- I Cinar
- Department of Pharmacology, Faculty of Medicine, Kafkas University, Kars, Turkey
| | - Z Halici
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - B Dincer
- Department of Pharmacology, Faculty of Pharmacy, Erzincan Binali Yildirim University, Erzincan, Turkey
| | - B Sirin
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - E Cadirci
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
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22
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Sivakumar K, Ragi TR. Understanding the cytotoxicity mitigation of 2-chlorophenothiazine/cyclodextrins through ‘ guest drug–host excipient’ encapsulation approach. J Biomol Struct Dyn 2020; 38:1565-1574. [DOI: 10.1080/07391102.2019.1600026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- K. Sivakumar
- Department of Chemistry, Faculty of Science, Sri Chandrasekharendra Saraswathi Viswa Mahavidyalaya (Deemed to be University), Enathur, Kanchipuram, Tamil Nadu, India
| | - T. R. Ragi
- Department of Chemistry, Faculty of Science, Sri Chandrasekharendra Saraswathi Viswa Mahavidyalaya (Deemed to be University), Enathur, Kanchipuram, Tamil Nadu, India
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23
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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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24
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Wilcock A, Charlesworth S, Prentice W, Selby P, McKenna M, Cripps S, Considine A, Orr A, Wright M, Mihalyo M, Oxberry S. Prescribing in Chronic Severe Hepatic Impairment. J Pain Symptom Manage 2019; 58:515-537. [PMID: 31077785 DOI: 10.1016/j.jpainsymman.2019.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 12/29/2022]
Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available via www.palliativedrugs.com. The series editors welcome feedback on the articles.
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Affiliation(s)
- Andrew Wilcock
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom.
| | - Sarah Charlesworth
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Wendy Prentice
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Paul Selby
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Maria McKenna
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Sarah Cripps
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Aisling Considine
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Alison Orr
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Mark Wright
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Mary Mihalyo
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Stephen Oxberry
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
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Hepatitis, Interstitial Nephritis, and Pancreatitis in Association With Clozapine Treatment: A Systematic Review of Case Series and Reports. J Clin Psychopharmacol 2018; 38:520-527. [PMID: 30059436 DOI: 10.1097/jcp.0000000000000922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/BACKGROUND Clozapine is the criterion standard in treatment-resistant schizophrenia. We sought to review data on several inflammatory effects associated with clozapine, specifically interstitial nephritis, hepatitis, and pancreatitis. METHODS/PROCEDURES We conducted a systematic review to identify studies, published up until December 2017, describing clozapine-induced hepatitis, nephritis, and pancreatitis. The primary objective was to characterize the clinical characteristics associated with each of the specific inflammatory reactions to clozapine. FINDINGS/RESULTS We identified 42 cases of inflammatory reactions associated with clozapine treatment- 20 :cases of clozapine-induced hepatitis, 11 cases of nephritis, and 11 of pancreatitis. The mean (SD) age was 38.8 (11.9) years. The mean (SD) dose of clozapine used was 252.4 (133.7) mg. Time to onset of pancreatitis (17.9 [11.2] days; range 4-35 days) was shorter than that for hepatitis (34.2 [20.1] days; range, 12-90 days) and nephritis (27.9 [27.0]; range, 8-90 days) but was not statistically significant (F = 2.267, P = 0.117). The mean (SD) time to recovery was shorter for cases of pancreatitis (15.7 [18.4] days) compared with cases of hepatitis (25.9 [16.5] days) and nephritis (24.5 [18.9] days). Three cases with hepatitis died. Seven of the cases had a clozapine rechallenge (hepatitis [n = 3], nephritis [n = 1], pancreatitis [n = 3]), with 5 having a recurrence at a mean (SD) onset of 3.5 (2.5) days (range, 1-7 days); 2 hepatitis cases were successfully rechallenged. IMPLICATIONS/CONCLUSIONS Clozapine-induced hepatitis, nephritis, and pancreatitis are uncommon adverse events, reflected in the paucity of case studies in the literature. Early recognition of the signs and symptoms of clozapine-associated hepatitis, nephritis, and pancreatitis is important, as when identified, clozapine should be urgently discontinued. Clozapine is associated with evidence of benign inflammatory processes; the extent to which hepatitis, and other inflammatory reactions, may be on a continuum with these more benign and self-limiting reactions is unclear, and this can only be resolved by prospectively following cohorts of clozapine-treated patients.
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Baeza I, de la Serna E, Calvo-Escalona R, Merchán-Naranjo J, Rodríguez-Latorre P, Martínez-Cantarero MC, Andrés P, Alda JA, Muñoz-Samons D, Ilzarbe D, Arango C, Castro-Fornieles J. One-Year Prospective Study of Liver Function Tests in Children and Adolescents on Second-Generation Antipsychotics: Is There a Link with Metabolic Syndrome? J Child Adolesc Psychopharmacol 2018; 28:463-473. [PMID: 29975563 DOI: 10.1089/cap.2017.0117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To analyze liver function tests (LFT), weight, metabolic syndrome (MetS) and at risk of meeting MetS criteria (AR-MetS) in children and adolescents on antipsychotics (AP) during a year-long follow-up. METHODS Two hundred sixteen patients, AP naïve or quasi-naïve (<30 days on AP), were included. Total bilirubin, the enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), weight and other parameters of MetS were measured at baseline, and at 3, 6 and 12 months, while patients remained on the same AP. RESULTS At baseline, patients (mean age: 14.1 ± 3.1 years; 60.2% male) were on risperidone (N = 143), olanzapine (N = 37), or quetiapine (N = 36), although the sample decreased over time to 67 patients at 12 months (risperidone N = 46, olanzapine N = 10, and quetiapine N = 11). Around 3% of patients had ALT/AST levels that were at least twice the upper limit of normal (ULN) at 3 and 6 months; whereas roughly 19% of patients had ALP levels that were at least twice the ULN in at least one assessment after baseline, but had no clinical symptoms. From baseline to 6 months, significant increases were observed in ALT levels in the whole sample (p = 0.005), whereas ALP increased only in patients on risperidone. Patients showed significant weight gain, and more individuals met criteria for MetS and AR-MetS over time (from baseline: 2.8% and 8.3%, to 1 year: 10.5% and 23.9%, respectively). There was a trend-level group effect in global ALT across time (p = 0.076). Patients with MetS showed higher ALT concentrations (28.9 [18.4-39.4] U/L) than AR-MetS (20.4 [8.5-32.2] U/L), and no-AR-MetS (19.2 [8.4-29.9] U/L). CONCLUSIONS Less than 3% of children and adolescents on AP during 1-year follow-up showed an increase in ALT or AST levels in one or more of the assessments, and none of these increases was of clinical significance. Patients with MetS and AR-MetS increased during this period, and the possible role of ALT levels to monitor these patients deserves further study.
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Affiliation(s)
- Inmaculada Baeza
- 1 Department of Child and Adolescent Psychiatry and Psychology, SGR-881, Institut Clinic of Neurosciences, Institut d'Investigacions Biomèdi ques August Pi Sunyer (IDIBAPS), Hospital Clínic Universitari of Barcelona , Barcelona, Spain .,2 Department of Medicine, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona , Barcelona, Spain
| | - Elena de la Serna
- 1 Department of Child and Adolescent Psychiatry and Psychology, SGR-881, Institut Clinic of Neurosciences, Institut d'Investigacions Biomèdi ques August Pi Sunyer (IDIBAPS), Hospital Clínic Universitari of Barcelona , Barcelona, Spain .,2 Department of Medicine, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona , Barcelona, Spain
| | - Rosa Calvo-Escalona
- 1 Department of Child and Adolescent Psychiatry and Psychology, SGR-881, Institut Clinic of Neurosciences, Institut d'Investigacions Biomèdi ques August Pi Sunyer (IDIBAPS), Hospital Clínic Universitari of Barcelona , Barcelona, Spain .,2 Department of Medicine, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona , Barcelona, Spain
| | - Jessica Merchán-Naranjo
- 3 Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón , School of Medicine, Universidad Complutense, IISGM, CIBERSAM, Madrid, Spain
| | - Pamela Rodríguez-Latorre
- 3 Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón , School of Medicine, Universidad Complutense, IISGM, CIBERSAM, Madrid, Spain
| | | | - Patricia Andrés
- 4 Child and Adolescent Psychiatry Department, Hospital Infantil Universitario Niño Jesús , Madrid, Spain
| | - José Angel Alda
- 5 Child and Adolescent Psychiatry Department, Hospital Sant Joan de Déu , CIBERSAM, Barcelona, Spain
| | - Daniel Muñoz-Samons
- 5 Child and Adolescent Psychiatry Department, Hospital Sant Joan de Déu , CIBERSAM, Barcelona, Spain
| | - Daniel Ilzarbe
- 6 Department of Child and Adolescent Psychiatry, Institute of Psychiatry , Psychology and Neuroscience, King's College London, London, United Kingdom .,7 Faculty of Medicine, Universitat de Barcelona , Barcelona, Spain
| | - Celso Arango
- 3 Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón , School of Medicine, Universidad Complutense, IISGM, CIBERSAM, Madrid, Spain
| | - Josefina Castro-Fornieles
- 1 Department of Child and Adolescent Psychiatry and Psychology, SGR-881, Institut Clinic of Neurosciences, Institut d'Investigacions Biomèdi ques August Pi Sunyer (IDIBAPS), Hospital Clínic Universitari of Barcelona , Barcelona, Spain .,2 Department of Medicine, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona , Barcelona, Spain
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Abstract
In October 2015, the drug-induced liver diseases group of the Chinese Society of Hepatology drafted and published the first Diagnosis and Treatment Guidelines on Drug-induced Liver Injury in China, giving suggestions on the diagnosis and treatment of drug-induced liver injury (DILI). As a psychiatrist, I have found that in clinical practice both typical and new antipsychotic drugs can induce liver injury to varying degrees. Therefore, it is necessary to quickly and accurately determine the cause of liver injury and the type and severity of injury and establish a solution. This article reviewed relevant literature including the common pathogenesis and clinical manifestations of drug-induced liver injury caused by antipsychotic drugs, laboratory tests, diagnostic criteria and classification, and clinical management strategies. This paper also includes a summary and a perspective on liver injury caused by antipsychotic drugs.
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Affiliation(s)
- Qinyu Lv
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenghui Yi
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abstract
The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.
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Solmi M, Murru A, Pacchiarotti I, Undurraga J, Veronese N, Fornaro M, Stubbs B, Monaco F, Vieta E, Seeman MV, Correll CU, Carvalho AF. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag 2017; 13:757-777. [PMID: 28721057 PMCID: PMC5499790 DOI: 10.2147/tcrm.s117321] [Citation(s) in RCA: 248] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.
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Affiliation(s)
- Marco Solmi
- Neuroscience Department, University of Padua
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Juan Undurraga
- Department of Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo
- Early Intervention Program, J. Horwitz Psychiatric Institute, Santiago, Chile
| | - Nicola Veronese
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- National Research Council, Ageing Section, Padua
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, School of Medicine, University “Federico II”, Naples, Italy
- New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Brendon Stubbs
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Francesco Monaco
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Eduard Vieta
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Christoph U Correll
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks
- Department of Psychiatry and Molecular Medicine Hempstead, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - André F Carvalho
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Translational Psychiatry Research Group and Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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Abstract
Psychiatric medications are used commonly in hospitalized patients and are particularly indicated in patients who are critically ill to manage many conditions. Due to their many indications in the intensive care unit (ICU), psychiatric medications should be closely monitored in these medically compromised patients for adverse reactions and medical complications because they may affect essentially all organ systems. These range from life-threatening reactions to other less significant effects, such as sedation, to other detrimental complications, such as pancreatitis. Knowledge of psychopharmacology as well as the diagnosis and treatment of these complications is imperative in treating patients in the ICU.
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Affiliation(s)
- Sheila C Lahijani
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Palo Alto, CA 94305, USA.
| | - Kirk A Harris
- Department of Psychiatry, Rush University, 1725 West Harrison Street, Suite 955, Chicago, IL 60612, USA
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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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Parasuraman S, Zhen KM, Banik U, Christapher PV. Ameliorative Effect of Curcumin on Olanzapine-induced Obesity in Sprague-Dawley Rats. Pharmacognosy Res 2017; 9:247-252. [PMID: 28827965 PMCID: PMC5541480 DOI: 10.4103/pr.pr_8_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the effect of curcumin on olanzapine-induced obesity in rats. MATERIALS AND METHODS Sprague-Dawley (SD) rats were used for experiments. The animals were divided into six groups, namely, normal control, olanzapine control, betahistine (10 mg/kg), and curcumin 50, 100, and 200 mg/kg treated groups. Except the normal control group, all other animals were administered with olanzapine 4 mg/kg intraperitoneally to induce obesity. The drugs were administered once daily, per oral for 28 days. During the experiment, body weight changes and behavior alterations were monitored at regular intervals. At the end of the experiment, blood sample was collected from all the experimental animals for biochemical analysis. Part of the liver and kidney tissues was harvested from the sacrificed animals and preserved in neutral formalin for histopathological studies. RESULTS Curcumin showed a significant reduction in olanzapine-induced body weight gain on the rats and improved the locomotor effects. The effect of curcumin on olanzapine-induced body weight gain is not comparable with that of betahistine. CONCLUSION This study has shown metabolic alteration effect of curcumin on olanzapine, an antipsychotic drug, treated SD rats. SUMMARY Olanzapine is an atypical antipsychotic drug used for the treatment of schizophrenia and bipolar disorder. Obesity is an adverse effect of olanzapine, and the present study was made an attempt to study the effect of curcumin on olanzapine-induced obesity in rats. In this present study, curcumin significantly reduced olanzapine-induced body weight gain in rats. Abbreviations Used: 5HT: 5-hydroxytryptamine, ALP: Alkaline phosphatase, ALT: Alanine transaminase, ANOVA: Analysis of variance, AST: Aspartate transaminase, CMC: Carboxymethyl cellulose, D: Dopamine, H and E: Hematoxylin and Eosin stain, H: Histamine, HDL-C: Highdensity lipoprotein cholesterol, IP: Intraperitoneal, MAO: Monoamine oxidase, NaOH: Sodium hydroxide, SD rats: Sprague Dawley rats, TCs: Total cholesterols, TG: Triglyceride.
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Affiliation(s)
| | - Khor Ming Zhen
- Unit of Pharmacology, Faculty of Pharmacy, AIMST University, Kedah, Malaysia
| | - Urmila Banik
- Department of Pathology, Faculty of Medicine, AIMST University, Kedah, Malaysia
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Nielsen SMB, Vinther-Jensen T, Nielsen JE, Nørremølle A, Hasholt L, Hjermind LE, Josefsen K. Liver function in Huntington's disease assessed by blood biochemical analyses in a clinical setting. J Neurol Sci 2016; 362:326-32. [DOI: 10.1016/j.jns.2016.02.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 02/05/2016] [Accepted: 02/07/2016] [Indexed: 12/12/2022]
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Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry 2015; 14:119-36. [PMID: 26043321 PMCID: PMC4471960 DOI: 10.1002/wps.20204] [Citation(s) in RCA: 499] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.
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Affiliation(s)
- Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, North Shore - Long Island Jewish Health SystemGlen Oaks, New York, NY, USA,Department of Psychiatry and Molecular Medicine, Hofstra North Shore LIJ School of MedicineHempstead, New York, NY, USA,Psychiatric Neuroscience Center of Excellence, Feinstein Institute for Medical ResearchManhasset, New York, NY, USA,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of MedicineBronx, New York, NY, USA
| | - Johan Detraux
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, University of LeuvenB-3000 Leuven, Belgium
| | - Marc De Hert
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
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Chraïbi Z, Ouldamer L, Body G, Bacq Y. Hyperemesis gravidarum : étude de cohorte rétrospective française (109 patientes). Presse Med 2015; 44:e13-22. [DOI: 10.1016/j.lpm.2014.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 04/09/2014] [Accepted: 04/16/2014] [Indexed: 12/27/2022] Open
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López-Torres E, Süveges A, Peñas-LLedó EM, Doña A, Dorado P, LLerena A, Berecz R. Liver enzyme abnormalities during antipsychotic treatment: a case report of risperidone-associated hepatotoxicity. ACTA ACUST UNITED AC 2014; 29:123-6. [PMID: 24598833 DOI: 10.1515/dmdi-2013-0064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/22/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drug-induced liver enzyme abnormalities may indicate hepatic injury. Antipsychotic drugs also may cause increase in the liver enzymes and serum bilirubin levels. The present report evaluates the case of a patient with risperidone-associated hepatocellular damage. CASE SUMMARY A 19-year-old Caucasian man was admitted to the Department of Psychiatry with paranoid schizophrenia and risperidone was administered in a gradually increasing dose up to 8 mg/day. After 3 weeks of treatment, he experienced asthenia and weight loss. The level of aspartate aminotransferase was 283 IU/L (normal: <30 IU/L), and the alanine aminotransferase level was 778 IU/L (normal: <36 IU/L). Treatment with risperidone was immediately discontinued. Six days after drug withdrawal, the alanine aminotransferase level fell more than 50%, and a complete return to normalcy was seen within 2 months. RESULTS In the present case, a possible causal association between risperidone and hepatocellular damage has been observed due to the temporal relationship between the administration of the drug and the onset of hepatic abnormalities, and a following rapid recovery after stopping the drug. As the hepatic damage could be related to the plasma concentration of risperidone which is highly influenced by the hepatic enzyme CYP2D6, the patient was genotyped for CYP2D6. He was classified as homozygous wild type for CYP2D6. CONCLUSIONS The risk for developing hepatotoxicity during risperidone therapy cannot be supported by the patient CYP2D6 genotype. In clinical practice, it may be recommended to obtain baseline liver function tests before starting risperidone and regular screening for liver enzyme changes during therapy.
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Antipsychotics and abnormal liver function tests. Clin Neuropharmacol 2012; 35:297-8. [PMID: 23151471 DOI: 10.1097/wnf.0b013e318278feeb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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