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Peraire M, Arnau-Peiró F, Benito A, Fuertes-Saiz A, Almodóvar-Fernández I, Haro G. Clozapine as a mood stabiliser for schizoaffective disorder: Effectiveness during a three-month follow-up. Prog Neuropsychopharmacol Biol Psychiatry 2024; 135:111090. [PMID: 39019430 DOI: 10.1016/j.pnpbp.2024.111090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 07/13/2024] [Accepted: 07/14/2024] [Indexed: 07/19/2024]
Abstract
Clozapine has shown signs of effectiveness in treating symptoms of schizoaffective disorder, although little research has been carried out to specifically assess this question. The objective of this current work was to analyse the mood-stabilising effectiveness and tolerability of clozapine in patients with schizoaffective disorder. This was a prospective, longitudinal, and quasi-experimental trial with three months of follow-up in patients with refractory schizoaffective disorder (PANSS score exceeding 80). Clinical response was evaluated through monthly visits using the YMRS, MADRS, CDSS, CGI-S and UKU. Twenty-seven participants (63% men, 37% women) with a mean age of 32.56 years were included. Clozapine significantly reduced the symptoms of mania, as measured by the YMRS (pre-treatment: 16.19, post-treatment: 0.67; p < 0.01) as well as the symptoms of depression, quantified with the CDSS (pre-treatment: 6.11, post-treatment: 0.67; p < 0.01), MADRS (pre-treatment: 9.56, post-treatment: 1.07; p < 0.01), and CGI-S (pre-treatment: 4.74, post-treatment: 1.15; p < 0.01). The prescription of clozapine significantly reduced the average daily dose of neuroleptics, measured in mg of chlorpromazine (pre-treatment: 1253.55, post-treatment: 742.59; p < 0.01) and hypnosedatives, measured in mg of diazepam (pre-treatment: 33.88, post-treatment: 5.74; p < 0.05) required in these patients. Patient-perceived tolerability, measured with the UKU, also improved during follow-up (pre-treatment: 12.89, post-treatment: 8.14; p < 0.01). The efficacy of clozapine was significant for the affective symptoms of schizoaffective disorder, thereby improving patient tolerability and permitting reductions in the other medications the patients used.
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Affiliation(s)
- Marc Peraire
- TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Spain; Department of Mental Health, Provincial Hospital Consortium of Castellon, Spain.
| | - Francisco Arnau-Peiró
- TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Spain; Department of Mental Health, Provincial Hospital Consortium of Castellon, Spain
| | - Ana Benito
- TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Spain; Torrent Mental Health Unit, General University Hospital of Valencia, Spain
| | - Alejandro Fuertes-Saiz
- TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Spain; Treatment Resistant Depression Unit, Psychiatric Service, Hospital La Salud, Spain
| | | | - Gonzalo Haro
- TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Spain; Department of Mental Health, Provincial Hospital Consortium of Castellon, Spain
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Pechuán E, Toll A, Bergé D, Legido T, Martínez-Sadurní L, Trabsa A, De Iturbe G, Fernández SG, Jiménez-Fernández B, Fernández A, Pérez-Solà V, Mané A. Clozapine use in the first two years after first-episode psychosis in a real-world clinical sample. SPANISH JOURNAL OF PSYCHIATRY AND MENTAL HEALTH 2024:S2950-2853(24)00035-8. [PMID: 38908404 DOI: 10.1016/j.sjpmh.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/26/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Approximately 20-30% of patients with schizophrenia fail to respond to antipsychotic treatment and are considered treatment resistant (TR). Although clozapine is the treatment of choice in these patients, in real-world clinical settings, clinicians often delay clozapine initiation, especially in first-episode psychosis (FEP). AIM The main aim of this study was to describe prescription patterns for clozapine in a sample of patients diagnosed with FEP and receiving specialized treatment at a university hospital. More specifically, we aimed to determine the following: (1) the proportion of patients who received clozapine within two years of disease onset, (2) baseline predictors of clozapine use, (3) time from starting the first antipsychotic to clozapine initiation, (4) concomitant medications, and (5) clozapine-related adverse effects. METHODS All patients admitted to a specialized FEP treatment unit at our hospital between April 2013 and July 2020 were included and followed for two years. The following variables were assessed: baseline sociodemographic characteristics; medications prescribed during follow-up; clozapine-related adverse effects; and baseline predictors of clozapine use. We classified the sample into three groups: clozapine users, clozapine-eligible, and non-treatment resistant (TR). RESULTS A total of 255 patients were consecutively included. Of these, 20 (7.8%) received clozapine, 57 (22.4%) were clozapine-eligible, and 178 (69.8%) were non-TR. The only significant variable associated with clozapine use at baseline was the Global Assessment of Functioning (GAF) score (R2=0.09, B=-0.07; OR=0.94; 95% CI: 0.88-0.99; p=0.019). The median time to clozapine initiation was 55.0 (93.3) days. The most common side effect was sedation. CONCLUSIONS A significant proportion (30.2%) of patients in this cohort were treatment resistant and eligible for clozapine. However, only 7.8% of the sample received clozapine, indicating that this medication was underprescribed. A lower baseline GAF score was associated with clozapine use within two years, suggesting that it could be used to facilitate the early identification of patients who will need treatment with clozapine, which could in turn improve treatment outcomes.
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Affiliation(s)
- Emilio Pechuán
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain
| | - Alba Toll
- Departament de Psiquiatria, Hospital Universitari Germans Trias i Pujol (HGTiP), Badalona (Barcelona), Spain; Institut de Recerca Germans Trias i Pujol (IGTP), Badalona (Barcelona), Spain; Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain.
| | - Daniel Bergé
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Teresa Legido
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Laura Martínez-Sadurní
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Amira Trabsa
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Gonzalo De Iturbe
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain
| | - Sara García Fernández
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain
| | - Beltran Jiménez-Fernández
- Departament de Psiquiatria, Hospital Universitari Germans Trias i Pujol (HGTiP), Badalona (Barcelona), Spain
| | - Aurea Fernández
- Departament de Psiquiatria, Hospital Universitari Germans Trias i Pujol (HGTiP), Badalona (Barcelona), Spain; Institut de Recerca Germans Trias i Pujol (IGTP), Badalona (Barcelona), Spain; Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Víctor Pérez-Solà
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Anna Mané
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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3
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Muñoz-Manchado LI, Perez-Revuelta JI, Banerjee A, Galindo-Guarin L, Bernardo M, González-Saiz F, Villagrán-Moreno JM, Fernández-Egea E. Influence of time to clozapine prescription on the clinical outcome. Schizophr Res 2024; 268:189-192. [PMID: 37805277 DOI: 10.1016/j.schres.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/24/2023] [Accepted: 09/14/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND This study investigates whether early clozapine use is associated with improved responses in different clinical domains, including positive and negative symptoms, functioning, and well-being. METHODS Data from 254 clozapine-treated patients at Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) were analysed. Among them, 231 (90.9 %) had a diagnosis of schizophrenia, 21 (8.3 %) schizoaffective disorder, and 2 (0.8 %) had other diagnoses. The International Classification of Diseases-Mortality and Morbidity Statistics criteria (ICD-10) were employed (World Health Organization, 1992). The cohort was assessed using the positive and negative syndrome scale (PANSS), the Brief Negative Symptom Scale (BNSS), Global Assessment of Functioning Scale (GAF), and the short version of Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). Logistic regression models (for positive and negative symptom remission) and linear regression (for functioning and well-being) were utilized to assess the influence of time to clozapine initiation (TCI), age at the first episode of psychosis (AFE), duration of clozapine treatment (DCT), and gender. RESULTS Early clozapine treatment (within the first three years after the first episode of psychosis) was associated with increased negative symptom remission (exp (B) = 0.38; p = 0.02) and higher functioning scores (β = -0.12, p = 0.046). However, no effect of time to clozapine initiation was found on positive symptom remission rates or well-being scores. CONCLUSIONS Initiating clozapine treatment within the first 3 years of the first episode of psychosis may lead to reduced severity of negative symptoms and improved functioning in clozapine-treated patients. The time to clozapine initiation did not influence its effect on positive symptom remission rates.
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Affiliation(s)
- Leticia I Muñoz-Manchado
- Department of Psychiatry, Behavioral and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom; Unidad de Gestión clínica de Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Hospital Universitario de Jerez de la Frontera, Severe Mental Disorder Research Group, Department of Neuroscience, University of Cádiz, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, Spain.
| | - Jose I Perez-Revuelta
- Unidad de Gestión clínica de Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Hospital Universitario de Jerez de la Frontera, Severe Mental Disorder Research Group, Department of Neuroscience, University of Cádiz, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, Spain.
| | - Arka Banerjee
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Liliana Galindo-Guarin
- Department of Psychiatry, Behavioral and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom.
| | - Miguel Bernardo
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Barcelona Clinic Schizophrenia Unit, Hospital Clínic de Barcelona, Departament de Medicina, Institut de Neurociències (UBNeuro), Universitat de Barcelona (UB), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 170, Villarroel St., 8037 Barcelona, Spain.
| | - Francisco González-Saiz
- Unidad de Gestión clínica de Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Hospital Universitario de Jerez de la Frontera, Severe Mental Disorder Research Group, Department of Neuroscience, University of Cádiz, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
| | - J M Villagrán-Moreno
- Unidad de Gestión clínica de Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Hospital Universitario de Jerez de la Frontera, Severe Mental Disorder Research Group, Department of Neuroscience, University of Cádiz, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
| | - Emilio Fernández-Egea
- Department of Psychiatry, Behavioral and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom.
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Wagner E, Borgwardt S, Hasan A. [Management of treatment resistance-Treatment-resistant schizophrenia]. DER NERVENARZT 2024; 95:423-431. [PMID: 38319320 DOI: 10.1007/s00115-024-01608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/07/2024]
Abstract
Despite a very high prevalence and substantial impairments among affected individuals, treatment-resistant schizophrenia (TRS) has not been sufficiently researched in clinical research in the field of psychiatric disorders and the pathophysiology is still poorly understood. A better clinical and pathophysiological understanding of this heterogeneous and severely affected population of people with persistent symptoms in different domains is necessary in order not only to be able to intervene early but also to develop novel therapeutic strategies or individualized treatment approaches. This review article presents the state of the art criteria of the pharmacological TRS, neurobiological disease models and predictive factors for TRS as well as the phenomenon of pseudo-treatment resistance and the clinical management of TRS. In the future, not only the use of operationalized criteria and definitions of TRS in longitudinal studies and randomized-controlled trials (RCTs) are paramount, but also the observation of trajectories with the integration of multimodal longitudinal phenotyping and the longitudinal collection of clinical routine data in academic research, which will be possible in the newly created German Center for Mental Health (DZPG).
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Affiliation(s)
- Elias Wagner
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland.
- Evidenzbasierte Psychiatrie und Psychotherapie, Medizinische Fakultät, Universität Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - Stefan Borgwardt
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Lübeck, Deutschland
| | - Alkomiet Hasan
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland
- Deutsches Zentrum für psychische Gesundheit, Augsburg, Deutschland
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5
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Tiwari A, Kambhatla S, George N, Anumolu P, Malik N, Kambhatla S. Clozapine-Related Functional Bowel Obstruction: A Rare Adverse Effect Unmasking Quetiapine and Benztropine Interaction Raising Need for Bowel Surveillance. ACG Case Rep J 2024; 11:e01351. [PMID: 38764552 PMCID: PMC11101216 DOI: 10.14309/crj.0000000000001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/28/2024] [Indexed: 05/21/2024] Open
Abstract
Randomized controlled trials demonstrate a significant decline in hospital admissions and length of stay following the initiation of clozapine in individuals with bipolar disorder and schizophrenia, along with an increase in quality-adjusted life years. The morbidity and mortality associated with clozapine-induced gastrointestinal hypomotility (CIGH) is greater than agranulocytosis. Despite this, we only have clozapine risk evaluation and mitigation strategies by the US Food and Drug Administration for white cell count monitoring, but none exists for CIGH. Our case highlights CIGH due to multiple factors and recommendations to prevent it and enhance clozapine compliance by conducting a thorough literature review.
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Affiliation(s)
- Apoorv Tiwari
- Department of Internal Medicine, Michigan State University, Garden City Hospital, Garden City, MI
| | | | | | - Prathyusha Anumolu
- Department of Internal Medicine, Michigan State University, Garden City Hospital, Garden City, MI
| | - Nikhale Malik
- Department of Internal Medicine, Michigan State University, Garden City Hospital, Garden City, MI
| | - Sujata Kambhatla
- Department of Internal Medicine, Michigan State University, Garden City Hospital, Garden City, MI
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Gleisner BM, Deardorff OG, Liu Y, Trout MG, Wood JR, Sommi RW, Beck NC. Impact of COVID-19 quarantines on clozapine-induced constipation: Experience of utilizing a clozapine-induced constipation protocol at a state forensic psychiatric facility. Ment Health Clin 2024; 14:68-72. [PMID: 38312438 PMCID: PMC10836562 DOI: 10.9740/mhc.2024.02.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/14/2023] [Indexed: 02/06/2024] Open
Abstract
Objective Since 2017, Fulton State Hospital (FSH) has implemented a clozapine-induced constipation protocol. In March 2020, FSH initiated unit quarantines to minimize the spread of coronavirus disease (COVID-19). The objective of this study was to evaluate the impact of these quarantines on medical referrals for constipation, the Bristol Stool Chart ratings, utilization of as-needed (PRN) laxatives, and adherence rates with scheduled constipation medication regimens. Methods Patients on the clozapine-induced constipation protocol from May 1, 2019 to December 31, 2020, were included, with 10-month pre- and mid-quarantine implementation. Data collected included patient demographics, primary psychiatric diagnosis, and outcome variables. Descriptive statistics and paired t-tests were performed. Results A total of 31 patients were included. Most were male (93.5%), with a median age of 40 years. The most common primary diagnosis was schizophrenia. Compared with the pre-quarantine implementation period, there were fewer medical referral contacts per person, less use of PRN laxatives, and slightly lower adherence rates to scheduled constipation medication regimens during the mid-quarantine implementation period. Conclusion Compared with the pre-quarantine implementation period, there were fewer medical referrals per person during the mid-quarantine implementation period.
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Affiliation(s)
| | - O Greg Deardorff
- Clinical Pharmacy Manager, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
| | - Yifei Liu
- Clinical Operational Pharmacist, McLean Hospital, Belmont, Massachusettes
- Clinical Pharmacy Manager, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
- Clinical Pharmacist, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
- Clinical Pharmacist, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
- Professor Emeritus, Division of Pharmacy Practice and Administration, University of Missouri - Kansas City School of Pharmacy, Kansas City, Missouri
- Professor Emeritus, Department of Psychiatry, University of Missouri Health Care, Columbia, Missouri
| | - Megan G Trout
- Clinical Pharmacist, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
| | - Joshua R Wood
- Clinical Pharmacist, Department of Pharmacy, Fulton State Hospital, Fulton, Missouri
| | - Roger W Sommi
- Professor Emeritus, Division of Pharmacy Practice and Administration, University of Missouri - Kansas City School of Pharmacy, Kansas City, Missouri
| | - Niels C Beck
- Professor Emeritus, Department of Psychiatry, University of Missouri Health Care, Columbia, Missouri
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [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: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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8
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Kuzo N, Haen E, Ho DM, Takeuchi H, Piras M, Eap CB, de Filippis R, Homan P, Kane JM, Roy MA, Paulzen M, Schoretsanitis G. Clozapine once- versus multiple-daily dosing: a two-center cross-sectional study, systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci 2023; 273:1567-1578. [PMID: 36580106 PMCID: PMC10465369 DOI: 10.1007/s00406-022-01542-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/16/2022] [Indexed: 12/30/2022]
Abstract
Evidence regarding effectiveness and safety of clozapine once- vs. multiple-daily dosing is limited. We compared demographic and clinical parameters between patients with once- vs. multiple-daily dosing in the Department of Psychiatry and Psychotherapy, University of Regensburg, Germany (AGATE dataset), and the Department of Psychiatry, Lausanne University Hospital, Switzerland, using non-parametric tests. Effectiveness and safety outcomes were available in the AGATE dataset. We performed a systematic review in PubMed/Embase until February 2022, meta-analyzing studies comparing clozapine once- vs. multiple-daily-dosing. We estimated a pooled odds ratio for adverse drug-induced reactions (ADRs) and meta-analyzed differences regarding clinical symptom severity, age, percentage males, smokers, clozapine dose, and co-medications between patients receiving once- vs. multiple-daily dosing. Study quality was assessed using the Newcastle-Ottawa-Scale. Of 1494 and 174 patients included in AGATE and Lausanne datasets, clozapine was prescribed multiple-daily in 74.8% and 67.8%, respectively. In the AGATE cohort, no differences were reported for the clinical symptoms severity or ADR rate (p > 0.05). Meta-analyzing eight cohorts with a total of 2810 clozapine-treated individuals, we found more severe clinical symptoms (p = 0.036), increased ADR risk (p = 0.01), higher clozapine doses (p < 0.001), more frequent co-medication with other antipsychotics (p < 0.001), benzodiazepines (p < 0.001), anticholinergics (p = 0.039), and laxatives (p < 0.001) in patients on multiple- vs. once-daily dosing. Of six studies, five were rated as good, and one as poor quality. Patients responding less well to clozapine may be prescribed higher doses multiple-daily, also treated with polypharmacy, potentially underlying worse safety outcomes. Patient preferences and adherence should be considered during regimen selection.
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Affiliation(s)
- Nazar Kuzo
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatry University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zürich, Zurich, Switzerland
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Dominic M Ho
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatry University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Marianna Piras
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Chin-Bin Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Philipp Homan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatry University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Marc-André Roy
- Département de Psychiatrie et Neurosciences, Université Laval, Québec City, QC, Canada
- Centre de Recherche CERVO, Quebec City, QC, Canada
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, JARA Translational Brain Medicine, RWTH Aachen University, Aachen, Germany
- Alexianer Hospital Aachen, Aachen, Germany
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatry University Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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Muñoz-Manchado LI, Villagrán-Moreno JM, Palacios-Garrán R, Pérez-Revuelta JI. Looking to the future after reintroduction of clozapine. SPANISH JOURNAL OF PSYCHIATRY AND MENTAL HEALTH 2023; 16:266-267. [PMID: 38591738 DOI: 10.1016/j.sjpmh.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/31/2023] [Indexed: 04/10/2024]
Affiliation(s)
- Leticia I Muñoz-Manchado
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain.
| | - Jose María Villagrán-Moreno
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain; Department of Psychiatry, University of Cádiz, Cádiz, Spain
| | - Roberto Palacios-Garrán
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain
| | - Jose Ildefonso Pérez-Revuelta
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain; Department of Psychiatry, University of Cádiz, Cádiz, Spain
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10
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Bunting A, Silman D, Karia M, Johnson S. Clozapine and Sweet's syndrome: case report. BJPsych Open 2023; 9:e166. [PMID: 37665047 PMCID: PMC10486232 DOI: 10.1192/bjo.2023.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/20/2023] [Accepted: 06/06/2023] [Indexed: 09/05/2023] Open
Abstract
A patient developed fever, raised inflammatory markers and a maculopapular rash following commencement of clozapine for treatment of his schizoaffective disorder. Skin biopsy confirmed Sweet's syndrome. Identification of the cause was challenging, with a number of possible considerations including infection, malignancy and various potential drug triggers.This case highlights the difficulties in the diagnosis of Sweet's syndrome, as well as in identifying the original trigger, which can have significant consequences for management. Withdrawal of potentially causative drugs must be balanced with their benefits, and decisions must be made in the best interests of the patient. Following two courses of prednisolone and withdrawal of clozapine, the patient's rash and systemic symptoms resolved. This confirmed the diagnosis of drug-induced Sweet's syndrome, with clozapine as the offending agent. His mental state stabilised on an alternative antipsychotic.
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Affiliation(s)
- Apphia Bunting
- Oxford Health Foundation Trust, Warneford Hospital, Oxford, UK
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11
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Wagner E, Strube W, Görlitz T, Aksar A, Bauer I, Campana M, Moussiopoulou J, Hapfelmeier A, Wagner P, Egert-Schwender S, Bittner R, Eckstein K, Nenadić I, Kircher T, Langguth B, Meisenzahl E, Lambert M, Neff S, Malchow B, Falkai P, Hirjak D, Böttcher KT, Meyer-Lindenberg A, Blankenstein C, Leucht S, Hasan A. Effects of Early Clozapine Treatment on Remission Rates in Acute Schizophrenia (The EARLY Trial): Protocol of a Randomized-Controlled Multicentric Trial. PHARMACOPSYCHIATRY 2023; 56:169-181. [PMID: 37506738 PMCID: PMC10484642 DOI: 10.1055/a-2110-4259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/15/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Quick symptomatic remission after the onset of psychotic symptoms is critical in schizophrenia treatment, determining the subsequent disease course and recovery. In this context, only every second patient with acute schizophrenia achieves symptomatic remission within three months of initiating antipsychotic treatment. The potential indication extension of clozapine-the most effective antipsychotic-to be introduced at an earlier stage (before treatment-resistance) is supported by several lines of evidence, but respective clinical trials are lacking. METHODS Two hundred-twenty patients with acute non-treatment-resistant schizophrenia will be randomized in this double-blind, 8-week parallel-group multicentric trial to either clozapine or olanzapine. The primary endpoint is the number of patients in symptomatic remission at the end of week 8 according to international consensus criteria ('Andreasen criteria'). Secondary endpoints and other assessments comprise a comprehensive safety assessment (i. e., myocarditis screening), changes in psychopathology, global functioning, cognition, affective symptoms and quality of life, and patients' and relatives' views on treatment. DISCUSSION This multicentre trial aims to examine whether clozapine is more effective than a highly effective second-generation antipsychotics (SGAs), olanzapine, in acute schizophrenia patients who do not meet the criteria for treatment-naïve or treatment-resistant schizophrenia. Increasing the likelihood to achieve symptomatic remission in acute schizophrenia can improve the overall outcome, reduce disease-associated burden and potentially prevent mid- and long-term disease chronicity.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Wolfgang Strube
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Thomas Görlitz
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Aslihan Aksar
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Ingrid Bauer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Mattia Campana
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Joanna Moussiopoulou
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of AI and Informatics in Medicine, School of Medicine,
Technical University of Munich, Munich, Germany
- Institute of General Practice and Health Services Research, School of
Medicine, Technical University of Munich, Munich, Germany
| | - Petra Wagner
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Silvia Egert-Schwender
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Robert Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy,
University Hospital Frankfurt, Frankfurt, Germany
| | - Kathrin Eckstein
- Clinic for Psychiatry and Psychotherapy, University of
Tübingen, Tübingen, Germany
| | - Igor Nenadić
- Department of Psychiatry and Psychotherapy, Philipps-University
Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University
Marburg, Marburg, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg,
Regensburg, Germany
| | - Eva Meisenzahl
- Department of Psychiatry and Psychotherapy, LVR-Klinikum
Düsseldorf, Kliniken der Heinrich-Heine-Universität
Düsseldorf, Düsseldorf, Germany
| | - Martin Lambert
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial
Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg,
Germany
| | - Sigrid Neff
- Department of Psychiatry and Psychotherapy 1 und 2,
Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz,
Alzey, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center
Göttingen, Göttingen, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Dusan Hirjak
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Kent-Tjorben Böttcher
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Christiane Blankenstein
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of
Munich, School of Medicine, Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
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12
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Tabrisi R, Harun-Rashid MD, Montero J, Venizelos N, Msghina M. Clozapine but not lithium reverses aberrant tyrosine uptake in patients with bipolar disorder. Psychopharmacology (Berl) 2023; 240:1667-1676. [PMID: 37318540 PMCID: PMC10349740 DOI: 10.1007/s00213-023-06397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
RATIONALE Availability of the dopamine and noradrenaline precursor tyrosine is critical for normal functioning, and deficit in tyrosine transport across cell membrane and the blood-brain barrier has been reported in bipolar disorder and schizophrenia. Clozapine and lithium are two psychoactive agents used to treat psychosis, mood disorders and suicidal behavior, but their mechanism of action remains largely unknown. OBJECTIVE To characterize immediate and delayed differences in tyrosine uptake between healthy controls (HC) and bipolar patients (BP) and see if these differences could be normalized by either clozapine, lithium or both. A second objective was to see if clozapine and lithium have additive, antagonistic or synergistic effects in this. METHOD Fibroblasts from five HC and five BP were incubated for 5 min or 6 h with clozapine, lithium, or combination of both. Radioactive labelled tyrosine was used to quantify tyrosine membrane transport. RESULTS There was significantly reduced tyrosine uptake at baseline in BP compared to HC, a deficit that grew with increasing incubation time. Clozapine selectively increased tyrosine uptake in BP and abolished the deficit seen under baseline conditions, while lithium had no such effect. Combination treatment with clozapine and lithium was less effective than when clozapine was used alone. CONCLUSIONS There was significant deficit in tyrosine transport in BP compared to HC that was reversed by clozapine but not lithium. Clozapine was more effective when used alone than when added together with lithium. Potential clinical implications of this will be discussed.
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Affiliation(s)
- R Tabrisi
- Department of Plastic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M D Harun-Rashid
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Montero
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - N Venizelos
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Msghina
- Department of Psychiatry, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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13
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Wagner E, Siskind D, Falkai P, Howes O, Correll C, Lee J, Honer WG, Kane JM, Fernandez-Egea E, Barnes TRE, Hasan A. Clozapine Optimization: A Delphi Consensus Guideline From the Treatment Response and Resistance in Psychosis Working Group. Schizophr Bull 2023; 49:962-972. [PMID: 36943247 PMCID: PMC10318876 DOI: 10.1093/schbul/sbad030] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND HYPOTHESIS There is limited evidence to guide the approaches to clozapine treatment. Accordingly, an international initiative was undertaken with the aim of developing consensus recommendations for the optimization of clozapine monotherapy. STUDY DESIGN We conducted an online Delphi survey among members of the Treatment Response and Resistance in Psychosis (TRRIP) working group comprising experts from twenty-nine countries. The threshold criterion for a consensus recommendation was ≥ 75% agreement ("agree" and "strongly agree" responses) on a question. Agreement of ≥ 50% but < 75% in a second or third Delphi round was deemed to provide guidance. STUDY RESULTS Forty-nine (first round), 32 (second round), and 48 (third round) of the 91 current TRRIP members participated. Expert recommendations at ≥ 75% comprised second-line treatment with clozapine in cases of persistent positive symptoms with co-occurring extrapyramidal symptoms, tardive dyskinesia, or suicidality/aggression. There was considerable disagreement on myocarditis screening parameters. The management of somatic and neuropsychiatric adverse drug reactions warrants further research for more evidence-based recommendations. Rechallenge with clozapine was recommended for eosinophilia, sinus tachycardia and fever and guidance (agreement ≥ 50%) was reached for pneumonia and thrombocytopenia. CONCLUSIONS Given the limited evidence available, this consensus-based series of recommendations and guidance statements supports clinical decision-making to optimize clozapine monotherapy and provides guidance for future research in treatment-resistant schizophrenia.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
- Mobile Intensive Rehabilitation Team, Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Christoph Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin, Berlin, Germany
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore
- Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - William G Honer
- Department of Psychiatry, Institute of Mental Health, The University of British Columbia, Vancouver, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
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14
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Fukuyama K, Motomura E, Okada M. Enhanced L-β-Aminoisobutyric Acid Is Involved in the Pathophysiology of Effectiveness for Treatment-Resistant Schizophrenia and Adverse Reactions of Clozapine. Biomolecules 2023; 13:biom13050862. [PMID: 37238731 DOI: 10.3390/biom13050862] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Clozapine is an effective antipsychotic for the treatment of antipsychotic-resistant schizophrenia; however, specific types of A/B adverse effects and clozapine-discontinuation syndromes are also well known. To date, both the critical mechanisms of clinical actions (effective for antipsychotic-resistant schizophrenia) and the adverse effects of clozapine remain to be elucidated. Recently, we demonstrated that clozapine increased the synthesis of L-β-aminoisobutyric acid (L-BAIBA) in the hypothalamus. L-BAIBA is an activator of the adenosine monophosphate-activated protein kinase (AMPK), glycine receptor, GABAA receptor, and GABAB receptor (GABAB-R). These targets of L-BAIBA overlap as potential targets other than the monoamine receptors of clozapine. However, the direct binding of clozapine to these aminoacidic transmitter/modulator receptors remains to be clarified. Therefore, to explore the contribution of increased L-BAIBA on the clinical action of clozapine, this study determined the effects of clozapine and L-BAIBA on tripartite synaptic transmission, including GABAB-R and the group-III metabotropic glutamate receptor (III-mGluR) using cultured astrocytes, as well as on the thalamocortical hyper-glutamatergic transmission induced by impaired glutamate/NMDA receptors using microdialysis. Clozapine increased astroglial L-BAIBA synthesis in time/concentration-dependent manners. Increased L-BAIBA synthesis was observed until 3 days after clozapine discontinuation. Clozapine did not directly bind III-mGluR or GABAB-R, whereas L-BAIBA activated these receptors in the astrocytes. Local administration of MK801 into the reticular thalamic nucleus (RTN) increased L-glutamate release in the medial frontal cortex (mPFC) (MK801-evoked L-glutamate release). Local administration of L-BAIBA into the mPFC suppressed MK801-evoked L-glutamate release. These actions of L-BAIBA were inhibited by antagonists of III-mGluR and GABAB-R, similar to clozapine. These in vitro and in vivo analyses suggest that increased frontal L-BAIBA signaling likely plays an important role in the pharmacological actions of clozapine, such as improving the effectiveness of treating treatment-resistant schizophrenia and several clozapine discontinuation syndromes via the activation of III-mGluR and GABAB-R in the mPFC.
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Affiliation(s)
- Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
| | - Eishi Motomura
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
| | - Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan
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15
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Le Marois M, Sanson C, Maizières MA, Partiseti M, Bohme GA. The atypic antipsychotic clozapine inhibits multiple cardiac ion channels. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:161-166. [PMID: 36308551 DOI: 10.1007/s00210-022-02314-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/17/2022] [Indexed: 01/29/2023]
Abstract
Clozapine is an atypical neuroleptic used to manage treatment-resistant schizophrenia which is known to inhibit cardiac hERG/KV11.1 potassium channels, a pharmacological property associated with increased risk of potentially fatal Torsades de Pointes (TdP) and sudden cardiac death (SCD). Yet, the long-standing clinical practice of clozapine does not show a consistent association with increased incidence of TdP, although SCD is considerably higher among schizophrenic patients than in the general population. Here, we have established the inhibitory profile of clozapine at the seven cardiac ion currents proposed by the ongoing comprehensive in vitro pro-arrhythmia (CiPA) initiative to better predict new drug cardio-safety risk. We found that clozapine inhibited all CiPA currents tested with the following rank order of potency: KV11.1 > NaV1.5 (late current) ≈ CaV1.2 ≈ NaV1.5 (peak current) ≈ KV7.1 > KV4.3 > Kir2.1 (outward current). Half-maximal inhibitory concentrations (IC50) at the repolarizing KV11.1 and KV7.1 channels, and at the depolarizing CaV1.2 and NaV1.5 channels fell within a narrow half-log 3-10 µM concentration range, suggesting that mutual compensation could explain the satisfactory arrhythmogenic cardio-safety profile of clozapine. Although the IC50 values determined herein using an automated patch-clamp (APC) technique are at the higher end of clozapine plasmatic concentrations at target therapeutic doses, this effective antipsychotic appears prone to distribute preferentially into the cardiac tissue, which supports the clinical relevance of our in vitro pharmacological findings.
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Affiliation(s)
- Marguerite Le Marois
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Camille Sanson
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Magali-Anne Maizières
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Michel Partiseti
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - G Andrees Bohme
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France.
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Abstract
Antipsychotic polypharmacy in psychotic disorders is widespread despite international guidelines favoring monotherapy. Previous evidence indicates the utility of low-dose partial dopamine agonist (PDAs) add-ons to mitigate antipsychotic-induced metabolic adverse effects or hyperprolactinemia. However, clinicians are often concerned about using PDAs combined with high-potency, full dopaminergic antagonists (FDAs) due to the risk of psychosis relapse. We, therefore, conducted a literature review to find studies investigating the effects of combined treatment with PDAs (i.e. aripiprazole, cariprazine and brexpiprazole) and FDAs having a strong D 2 receptor binding affinity. Twenty studies examining the combination aripiprazole - high-potency FDAs were included, while no study was available on combinations with cariprazine or brexpiprazole. Studies reporting clinical improvement suggested that this may require a relatively long time (~11 weeks), while studies that found symptom worsening observed this happening in a shorter timeframe (~3 weeks). Patients with longer illness duration who received add-on aripiprazole on ongoing FDA monotherapy may be at greater risk for symptomatologic worsening. Especially in these cases, close clinical monitoring is therefore recommended during the first few weeks of combined treatment. These indications may be beneficial to psychiatrists who consider using this treatment strategy. Well-powered randomized clinical trials are needed to derive more solid clinical recommendations.
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17
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Clinical and treatment predictors of relapse during a three-year follow-up of a cohort of first episodes of schizophrenia. Schizophr Res 2022; 243:32-42. [PMID: 35231832 DOI: 10.1016/j.schres.2022.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/24/2021] [Accepted: 02/17/2022] [Indexed: 12/13/2022]
Abstract
Relapses are frequent in the first years following a first episode of schizophrenia (FES), being associated with a higher risk of developing a chronic psychotic disorder, and poor clinical and functional outcomes. The identification and intervention over factors associated with relapses in these early phases are timely and relevant. In this study, 119 patients in remission after a FES were closely followed over three years. Participants came from the 2EPS Project, a coordinated, naturalistic, longitudinal study of 15 tertiary centers in Spain. Sociodemographic, clinical, treatment and substance abuse data were analyzed. 49.6% of the participants relapsed during the 3-years follow-up. None of the baseline demographic and clinical characteristics analyzed showed a statistically significant association with relapses. 22% of patients that finished the follow-up without relapsing were not taking any antipsychotic. The group that relapsed presented higher mean antipsychotics doses (381.93 vs. 242.29 mg of chlorpromazine equivalent/day, p = 0.028) and higher rates of antipsychotic polytherapy (28.6% vs. 13%, p < 0.001), benzodiazepines use (30.8% vs. 8.5%, p < 0.001), side effects reports (39.2% vs. 25%, p = 0.022), psychological treatment (51.8% vs. 33.9%, p = 0.03), and cannabis consumption (93.2% vs. 56.7%, p < 0.001). Clozapine use was notably higher in the group that reminded in remission (21.7% vs. 8.2%, p < 0.019). These findings may guide clinicians to detect subgroups of patients with higher risk to present a second episode of psychosis, focusing on measures to ensure an adequate treatment or facilitating cannabis use cessation. This study supports future research to identify relapse prevention strategies for patients in early phases of schizophrenia.
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18
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Farooq S, Hattle M, Dazzan P, Kingstone T, Ajnakina O, Shiers D, Nettis MA, Lawrence A, Riley R, van der Windt D. Study protocol for the development and internal validation of Schizophrenia Prediction of Resistance to Treatment (SPIRIT): a clinical tool for predicting risk of treatment resistance to antipsychotics in first-episode schizophrenia. BMJ Open 2022; 12:e056420. [PMID: 35396294 PMCID: PMC8996048 DOI: 10.1136/bmjopen-2021-056420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/16/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Treatment-resistant schizophrenia (TRS) is associated with significant impairment of functioning and high treatment costs. Identification of patients at high risk of TRS at the time of their initial diagnosis may significantly improve clinical outcomes and minimise social and functional disability. We aim to develop a prognostic model for predicting the risk of developing TRS in patients with first-episode schizophrenia and to examine its potential utility and acceptability as a clinical decision tool. METHODS AND ANALYSIS We will use two well-characterised longitudinal UK-based first-episode psychosis cohorts: Aetiology and Ethnicity in Schizophrenia and Other Psychoses and Genetics and Psychosis for which data have been collected on sociodemographic and clinical characteristics. We will identify candidate predictors for the model based on current literature and stakeholder consultation. Model development will use all data, with the number of candidate predictors restricted according to available sample size and event rate. A model for predicting risk of TRS will be developed based on penalised regression, with missing data handled using multiple imputation. Internal validation will be undertaken via bootstrapping, obtaining optimism-adjusted estimates of the model's performance. The clinical utility of the model in terms of clinically relevant risk thresholds will be evaluated using net benefit and decision curves (comparative to competing strategies). Consultation with patients and clinical stakeholders will determine potential thresholds of risk for treatment decision-making. The acceptability of embedding the model as a clinical tool will be explored using qualitative focus groups with up to 20 clinicians in total from early intervention services. Clinicians will be recruited from services in Stafford and London with the focus groups being held via an online platform. ETHICS AND DISSEMINATION The development of the prognostic model will be based on anonymised data from existing cohorts, for which ethical approval is in place. Ethical approval has been obtained from Keele University for the qualitative focus groups within early intervention in psychosis services (ref: MH-210174). Suitable processes are in place to obtain informed consent for National Health Service staff taking part in interviews or focus groups. A study information sheet with cover letter and consent form have been prepared and approved by the local Research Ethics Committee. Findings will be shared through peer-reviewed publications, conference presentations and social media. A lay summary will be published on collaborator websites.
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Affiliation(s)
- Saeed Farooq
- Midlands Partnership NHS Foundation Trust, Stafford, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Miriam Hattle
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Paola Dazzan
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Tom Kingstone
- Midlands Partnership NHS Foundation Trust, Stafford, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Olesya Ajnakina
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Shiers
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Maria Antonietta Nettis
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, University of London, London, UK
| | - Andrew Lawrence
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, University of London, London, UK
| | - Richard Riley
- School of Medicine, Keele University, Keele, Staffordshire, UK
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19
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Genome-wide association analyses of symptom severity among clozapine-treated patients with schizophrenia spectrum disorders. Transl Psychiatry 2022; 12:145. [PMID: 35393395 PMCID: PMC8989876 DOI: 10.1038/s41398-022-01884-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/24/2022] [Accepted: 03/07/2022] [Indexed: 12/26/2022] Open
Abstract
Clozapine is the most effective antipsychotic for patients with treatment-resistant schizophrenia. However, response is highly variable and possible genetic underpinnings of this variability remain unknown. Here, we performed polygenic risk score (PRS) analyses to estimate the amount of variance in symptom severity among clozapine-treated patients explained by PRSs (R2) and examined the association between symptom severity and genotype-predicted CYP1A2, CYP2D6, and CYP2C19 enzyme activity. Genome-wide association (GWA) analyses were performed to explore loci associated with symptom severity. A multicenter cohort of 804 patients (after quality control N = 684) with schizophrenia spectrum disorder treated with clozapine were cross-sectionally assessed using the Positive and Negative Syndrome Scale and/or the Clinical Global Impression-Severity (CGI-S) scale. GWA and PRS regression analyses were conducted. Genotype-predicted CYP1A2, CYP2D6, and CYP2C19 enzyme activities were calculated. Schizophrenia-PRS was most significantly and positively associated with low symptom severity (p = 1.03 × 10-3; R2 = 1.85). Cross-disorder-PRS was also positively associated with lower CGI-S score (p = 0.01; R2 = 0.81). Compared to the lowest tertile, patients in the highest schizophrenia-PRS tertile had 1.94 times (p = 6.84×10-4) increased probability of low symptom severity. Higher genotype-predicted CYP2C19 enzyme activity was independently associated with lower symptom severity (p = 8.44×10-3). While no locus surpassed the genome-wide significance threshold, rs1923778 within NFIB showed a suggestive association (p = 3.78×10-7) with symptom severity. We show that high schizophrenia-PRS and genotype-predicted CYP2C19 enzyme activity are independently associated with lower symptom severity among individuals treated with clozapine. Our findings open avenues for future pharmacogenomic projects investigating the potential of PRS and genotype-predicted CYP-activity in schizophrenia.
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20
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Hribkova H, Svoboda O, Bartecku E, Zelinkova J, Horinkova J, Lacinova L, Piskacek M, Lipovy B, Provaznik I, Glover JC, Kasparek T, Sun YM. Clozapine Reverses Dysfunction of Glutamatergic Neurons Derived From Clozapine-Responsive Schizophrenia Patients. Front Cell Neurosci 2022; 16:830757. [PMID: 35281293 PMCID: PMC8904748 DOI: 10.3389/fncel.2022.830757] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/28/2022] [Indexed: 11/26/2022] Open
Abstract
The cellular pathology of schizophrenia and the potential of antipsychotics to target underlying neuronal dysfunctions are still largely unknown. We employed glutamatergic neurons derived from induced pluripotent stem cells (iPSC) obtained from schizophrenia patients with known histories of response to clozapine and healthy controls to decipher the mechanisms of action of clozapine, spanning from molecular (transcriptomic profiling) and cellular (electrophysiology) levels to observed clinical effects in living patients. Glutamatergic neurons derived from schizophrenia patients exhibited deficits in intrinsic electrophysiological properties, synaptic function and network activity. Deficits in K+ and Na+ currents, network behavior, and glutamatergic synaptic signaling were restored by clozapine treatment, but only in neurons from clozapine-responsive patients. Moreover, neurons from clozapine-responsive patients exhibited a reciprocal dysregulation of gene expression, particularly related to glutamatergic and downstream signaling, which was reversed by clozapine treatment. Only neurons from clozapine responders showed return to normal function and transcriptomic profile. Our results underscore the importance of K+ and Na+ channels and glutamatergic synaptic signaling in the pathogenesis of schizophrenia and demonstrate that clozapine might act by normalizing perturbances in this signaling pathway. To our knowledge this is the first study to demonstrate that schizophrenia iPSC-derived neurons exhibit a response phenotype correlated with clinical response to an antipsychotic. This opens a new avenue in the search for an effective treatment agent tailored to the needs of individual patients.
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Affiliation(s)
- Hana Hribkova
- Department of Biology, Masaryk University, Brno, Czechia
| | - Ondrej Svoboda
- Department of Biomedical Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czechia
| | - Elis Bartecku
- Department of Psychiatry, Faculty of Medicine and University Hospital Brno, Brno, Czechia
| | - Jana Zelinkova
- Department of Biology, Masaryk University, Brno, Czechia
| | - Jana Horinkova
- Department of Psychiatry, Faculty of Medicine and University Hospital Brno, Brno, Czechia
| | - Lubica Lacinova
- Center of Bioscience, Institute of Molecular Physiology and Genetics, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Martin Piskacek
- Department of Pathological Physiology, Masaryk University, Brno, Czechia
| | - Bretislav Lipovy
- Department of Burns and Plastic Surgery, Faculty of Medicine and University Hospital Brno, Brno, Czechia
| | - Ivo Provaznik
- Department of Biomedical Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czechia
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Joel C. Glover
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Norwegian Center for Stem Cell Research, Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Tomas Kasparek
- Department of Psychiatry, Faculty of Medicine and University Hospital Brno, Brno, Czechia
- *Correspondence: Tomas Kasparek,
| | - Yuh-Man Sun
- Department of Biology, Masaryk University, Brno, Czechia
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21
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Sasabayashi D, Takayanagi Y, Takahashi T, Furuichi A, Kobayashi H, Noguchi K, Suzuki M. Increased brain gyrification and subsequent relapse in patients with first-episode schizophrenia. Front Psychiatry 2022; 13:937605. [PMID: 36032231 PMCID: PMC9406142 DOI: 10.3389/fpsyt.2022.937605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Most schizophrenia patients experience psychotic relapses, which may compromise long-term outcome. However, it is difficult to objectively assess the actual risk of relapse for each patient as the biological changes underlying relapse remain unknown. The present study used magnetic resonance imaging (MRI) to investigate the relationship between brain gyrification pattern and subsequent relapse in patients with first-episode schizophrenia. The subjects consisted of 19 patients with and 33 patients without relapse during a 3-year clinical follow-up after baseline MRI scanning. Using FreeSurfer software, we compared the local gyrification index (LGI) between the relapsed and non-relapsed groups. In the relapsed group, we also explored the relationship among LGI and the number of relapses and time to first relapse after MRI scanning. Relapsed patients exhibited a significantly higher LGI in the bilateral parietal and left occipital areas than non-relapsed patients. In addition, the time to first relapse was negatively correlated with LGI in the right inferior temporal cortex. These findings suggest that increased LGI in the temporo-parieto-occipital regions in first-episode schizophrenia patients may be a potential prognostic biomarker that reflects relapse susceptibility in the early course of the illness.
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Affiliation(s)
- Daiki Sasabayashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Yoichiro Takayanagi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Arisawabashi Hospital, Toyama, Japan
| | - Tsutomu Takahashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Atsushi Furuichi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Haruko Kobayashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Kyo Noguchi
- Department of Radiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Michio Suzuki
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
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22
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Wagner E, Siafis S, Fernando P, Falkai P, Honer WG, Röh A, Siskind D, Leucht S, Hasan A. Efficacy and safety of clozapine in psychotic disorders-a systematic quantitative meta-review. Transl Psychiatry 2021; 11:487. [PMID: 34552059 PMCID: PMC8458455 DOI: 10.1038/s41398-021-01613-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023] Open
Abstract
A recent increase in the literature regarding the evidence base for clozapine has made it increasingly difficult for clinicians to judge "best evidence" for clozapine use. As such, we aimed at elucidating the state-of-the-art for clozapine with regard to efficacy, effectiveness, tolerability, and management of clozapine and clozapine-related adverse events in neuropsychiatric disorders. We conducted a systematic PRISMA-conforming quantitative meta-review of available meta-analytic evidence regarding clozapine use. Primary outcome effect sizes were extracted and transformed into relative risk ratios (RR) and standardized mean differences (SMD). The methodological quality of meta-analyses was assessed using the AMSTAR-2 checklist. Of the 112 meta-analyses included in our review, 61 (54.5%) had an overall high methodological quality according to AMSTAR-2. Clozapine appears to have superior effects on positive, negative, and overall symptoms and relapse rates in schizophrenia (treatment-resistant and non-treatment-resistant subpopulations) compared to first-generation antipsychotics (FGAs) and to pooled FGAs/second-generation antipsychotics (SGAs) in treatment-resistant schizophrenia (TRS). Despite an unfavorable metabolic and hematological adverse-event profile compared to other antipsychotics, hospitalization, mortality and all-cause discontinuation (ACD) rates of clozapine surprisingly show a pattern of superiority. Our meta-review outlines the superior overall efficacy of clozapine compared to FGAs and most other SGAs in schizophrenia and suggests beneficial efficacy outcomes in bipolar disorder and Parkinson's disease psychosis (PDP). More clinical studies and subsequent meta-analyses are needed beyond the application of clozapine in schizophrenia-spectrum disorders and future studies should be directed into multidimensional clozapine side-effect management to foster evidence and to inform future guidelines.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Spyridon Siafis
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Piyumi Fernando
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Peter Falkai
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - William G. Honer
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Astrid Röh
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Dan Siskind
- grid.1003.20000 0000 9320 7537School of Medicine, University of Queensland, Brisbane, Australia ,Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Stefan Leucht
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Alkomiet Hasan
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany ,grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
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23
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Kokurcan A, Güriz SO, Karadağ H, Erdi F, Örsel S. Treatment strategies in management of schizophrenia patients with persistent symptoms in daily practice: a retrospective study. Int J Psychiatry Clin Pract 2021; 25:238-244. [PMID: 33555218 DOI: 10.1080/13651501.2021.1879157] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES One-third of the patients with schizophrenia show treatment resistance and literature on the effectiveness of interventions in patients with persistent symptoms is conflicting. This study aimed to assess clinical preferences of clinicians in those showing treatment resistance to antipsychotics and to determine correlates of interventions. METHODS Treatment strategies applied in the patients with schizophrenia in daily practice were inquired retrospectively. Those showing poor response to at least two antipsychotics and were administered a clinical intervention in a University Hospital between January and September 2018 were included. Clinical correlates of distinct interventions were evaluated. RESULTS The most common intervention (47%) was transition to a long-acting injectable antipsychotic (LAIA) and the second most common (22%) was addition of a second/third oral drug to on-going oral therapy. Switching to clozapine was more effective on positive symptoms comparing with the other interventions (p < 0.01). LAIA therapy showed a superiority over oral antipsychotic interventions at improving positive symptoms, except clozapine (p < 0.01). CONCLUSIONS LAIA administration and oral antipsychotic augmentation were the most common interventions in the patients with persistent symptoms. Clozapine was related to better clinical improvement in the present study and it might be administered as a second-line treatment in schizophrenia.Key pointsEffectiveness of the treatment strategies in schizophrenia patients with persistent symptoms is not satisfactory to meet expectations of the clinicians yet. Clozapine still seems to be the best option to provide a favourable improvement in TRS.LAIA and oral AP combination are used frequently in schizophrenia for persistent psychotic symptoms and targets of the combination therapies in daily practice needs to be clarified.The most common intervention was transition to a LAIA (47%) in the study and none of the patients administered LAIA had used a long-acting AP before the intervention. High rate of treatment nonadherence in schizophrenia is an important reason for common LAIA preference in the patients with persistent symptoms.Growing evidence indicates that clozapine can be used as a second-line treatment in schizophrenia, and thus, there is an urgent need to increase clozapine use in the patients with persistent symptoms in clinical practice.
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Affiliation(s)
- Ahmet Kokurcan
- Department of Psychiatry, Faculty of Medicine, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Health Sciences University, Ankara, Turkey
| | - Seher Olga Güriz
- Department of Psychiatry, Faculty of Medicine, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Health Sciences University, Ankara, Turkey
| | - Hasan Karadağ
- Department of Psychiatry, Faculty of Medicine, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Health Sciences University, Ankara, Turkey
| | - Funda Erdi
- Department of Psychiatry, Faculty of Medicine, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Health Sciences University, Ankara, Turkey
| | - Sibel Örsel
- Department of Psychiatry, Faculty of Medicine, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Health Sciences University, Ankara, Turkey
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24
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Rentrop M, Huhn M, Schwerthöffer D. [Clozapine in the Treatment of Schizophrenic Psychosis: Patient Characteristics and Antipsychotic Combinations in One Cohort at a Psychiatric Care Hospital]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:622-629. [PMID: 34384116 DOI: 10.1055/a-1526-2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In many studies, clozapine has been reported to have superior effectiveness compared to other antipsychotics. So far there is little systematic data on the practice of clozapine prescription and characteristics of patients treated. METHOD Retrospective evaluation of all 392 treatment courses of inpatients with schizophrenic psychoses during one year. Detailed analysis of the patients treated with clozapine including the dosages and additional psychotropic medication. RESULT Patients treated with clozapine showed a higher disease severity than patients without clozapine. They received more frequently pharmacological combination therapies, which in some cases significantly contradicted the current guideline recommendations. CONCLUSION The results underline the pronounced disease severity of patients receiving clozapine treatment and substantiate evidence from the literature on the limited implementation of guidelines in prescribing practice. The study carried out serves as a pilot survey of a multicenter research project on the practice of prescribing clozapine in psychiatric hospitals in different German regions.
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Affiliation(s)
- Michael Rentrop
- Klinische Sozialpsychiatrie, Kbo-Inn-Salzach-Klinikum Wasserburg, Wasserburg / Inn, Wasserburg, Deutschland.,Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
| | - Maximilian Huhn
- Psychiatrie, Klinik für Psychiatrie und Psychotherapie, Klinikum Bamberg, Bamberg, Deutschland.,Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
| | - Dirk Schwerthöffer
- Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
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25
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Lähteenvuo M, Tiihonen J. Antipsychotic Polypharmacy for the Management of Schizophrenia: Evidence and Recommendations. Drugs 2021; 81:1273-1284. [PMID: 34196945 PMCID: PMC8318953 DOI: 10.1007/s40265-021-01556-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 12/13/2022]
Abstract
Schizophrenia is a debilitating illness with a lifetime prevalence estimate of 0.6% and consists of symptoms from the positive, negative, and cognitive domains. Social support, therapy, psychoeducation, and overall case management are very important aspects of the treatment of schizophrenia. However, as abnormalities in neurotransmission are one of the key findings of schizophrenia pathology, pharmacotherapies are cornerstones of the management of schizophrenia. Antipsychotics have been used as the primary pharmacological treatment of schizophrenia. These agents often have a good effect on reducing positive symptoms, but may not markedly improve negative symptoms or cognitive defects. However, at least 20% of individuals with schizophrenia do not experience a substantial response from monotherapy with antipsychotics. Further, despite evolving treatment protocols and advances in early recognition of the disorder, 70% of patients with schizophrenia require long-term, even lifetime, medication to control their symptoms and do not achieve complete recovery. To address these shortcomings, clinicians and research scientists have explored different combinations of treatments, polypharmacy, to improve the treatment of patients. Antipsychotic polypharmacy has been shown to cause more side effects than monotherapy, which is the main reason why most treatment guidelines caution against it. Antipsychotic monotherapy should be strived for and clozapine should be tried at the latest if two monotherapy trials with other antipsychotics have failed and no absolute contraindications exist. If residual symptoms exist despite trials of adequate dose and duration, other reasons that may reduce treatment effect should be ruled out. Long-acting injectables or blood concentration measurements should be considered to affirm compliance and proper serum levels. Antipsychotic polypharmacy should be considered and discussed with patients from whom the aforementioned procedures do not produce a satisfactory treatment result. In some cases, antipsychotic polypharmacy may produce better results than other forms of treatment augmentation, such as benzodiazepines. In particular, combining aripiprazole with clozapine may be effective in reducing treatment side effects or residual symptoms, and this is likely to hold true for combining other partial dopamine D2 agonists with clozapine as well, although currently scant data exist. More research is needed, both in controlled but also real-world settings, to define optimal antipsychotic polypharmacy and/or other psychotropic treatment augmentation strategies for specific patient groups and situations.
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Affiliation(s)
- Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland.
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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26
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Lahogue C, Pinault D. Frontoparietal anodal tDCS reduces ketamine-induced oscillopathies. Transl Neurosci 2021; 12:282-296. [PMID: 34239718 PMCID: PMC8240415 DOI: 10.1515/tnsci-2020-0157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/05/2021] [Accepted: 05/14/2021] [Indexed: 12/26/2022] Open
Abstract
During the prodromal phase of schizophrenia with its complex and insidious clinical picture, electroencephalographic recordings detect widespread oscillation disturbances (or oscillopathies) during the wake-sleep cycle. Neural oscillations are electrobiomarkers of the connectivity state within systems. A single-systemic administration of ketamine, a non-competitive NMDA glutamate receptor antagonist, transiently reproduces the oscillopathies with a clinical picture reminiscent of the psychosis prodrome. This acute pharmacological model may help the research and development of innovative treatments against psychotic transition. Transcranial electrical stimulation is recognized as an appropriate non-invasive therapeutic modality since it can increase cognitive performance and modulate neural oscillations with little or no side effects. Therefore, our objective was to set up, in the sedated adult rat, a stimulation method that is able to normalize ketamine-induced increase in gamma-frequency (30-80 Hz) oscillations and decrease in sigma-frequency (10-17 Hz) oscillations. Unilateral and bipolar frontoparietal (FP), transcranial anodal stimulation by direct current (<+1 mA) was applied in ketamine-treated rats. A concomitant bilateral electroencephalographic recording of the parietal cortex measured the stimulation effects on its spontaneously occurring oscillations. A 5 min FP anodal tDCS immediately and quickly reduced, significantly with an intensity-effect relationship, the ketamine-induced gamma hyperactivity, and sigma hypoactivity at least in the bilateral parietal cortex. A duration effect was also recorded. The tDCS also tended to diminish the ketamine-induced delta hypoactivity. These preliminary neurophysiological findings are promising for developing a therapeutic proof-of-concept against neuropsychiatric disorders.
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Affiliation(s)
- Caroline Lahogue
- Université de Strasbourg, Strasbourg, France
- INSERM U1114, Neuropsychologie Cognitive et Physiopathologie de la Schizophrénie, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Centre de Recherche en Biomédecine de Strasbourg (CRBS), Faculté de médecine, Strasbourg, France
| | - Didier Pinault
- Université de Strasbourg, Strasbourg, France
- INSERM U1114, Neuropsychologie Cognitive et Physiopathologie de la Schizophrénie, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Centre de Recherche en Biomédecine de Strasbourg (CRBS), Faculté de médecine, Strasbourg, France
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27
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Alvarez-Mon MA, Donat-Vargas C, Santoma-Vilaclara J, de Anta L, Goena J, Sanchez-Bayona R, Mora F, Ortega MA, Lahera G, Rodriguez-Jimenez R, Quintero J, Álvarez-Mon M. Assessment of Antipsychotic Medications on Social Media: Machine Learning Study. Front Psychiatry 2021; 12:737684. [PMID: 34867531 PMCID: PMC8637121 DOI: 10.3389/fpsyt.2021.737684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Antipsychotic medications are the first-line treatment for schizophrenia. However, non-adherence is frequent despite its negative impact on the course of the illness. In response, we aimed to investigate social media posts about antipsychotics to better understand the online environment in this regard. Methods: We collected tweets containing mentions of antipsychotic medications posted between January 1st 2019 and October 31st 2020. The content of each tweet and the characteristics of the users were analyzed as well as the number of retweets and likes generated. Results: Twitter users, especially those identified as patients, showed an interest in antipsychotic medications, mainly focusing on the topics of sexual dysfunction and sedation. Interestingly, paliperidone, despite being among one of the newest antipsychotics, accounted for a low number of tweets and did not generate much interest. Conversely, retweet and like ratios were higher in those tweets asking for or offering help, in those posted by institutions and in those mentioning cognitive complaints. Moreover, health professionals did not have a strong presence in tweet postings, nor did medical institutions. Finally, trivialization was frequently observed. Conclusion: This analysis of tweets about antipsychotic medications provides insights into experiences and opinions related to this treatment. Twitter user perspectives therefore constitute a valuable input that may help to improve clinicians' knowledge of antipsychotic medications and their communication with patients regarding this treatment.
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Affiliation(s)
- Miguel A Alvarez-Mon
- Department of Medicine and Medical Specialities, University of Alcala, Alcala de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), Madrid, Spain.,Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Carolina Donat-Vargas
- Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.,IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain
| | | | - Laura de Anta
- Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Javier Goena
- Department of Psychiatry and Clinical Psychology, University of Navarra Clinic, Pamplona, Spain.,Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Rodrigo Sanchez-Bayona
- Hospital Universitario 12 de Octubre, Unidad de Cáncer de Mama y Ginecológico, Madrid, Spain
| | - Fernando Mora
- Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, Madrid, Spain.,Department of Legal and Psychiatry, Complutense University, Madrid, Spain
| | - Miguel A Ortega
- Department of Medicine and Medical Specialities, University of Alcala, Alcala de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), Madrid, Spain
| | - Guillermo Lahera
- Department of Medicine and Medical Specialities, University of Alcala, Alcala de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), Madrid, Spain.,Department of Psychiatry, University Hospital Principe de Asturias, Alcalá de Henares, Spain.,CIBERSAM (Biomedical Research Networking Centre in Mental Health), Madrid, Spain
| | - Roberto Rodriguez-Jimenez
- CIBERSAM (Biomedical Research Networking Centre in Mental Health), Madrid, Spain.,Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas 12), Madrid, Spain.,Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Javier Quintero
- Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, Madrid, Spain.,Department of Legal and Psychiatry, Complutense University, Madrid, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, University of Alcala, Alcala de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), Madrid, Spain.,Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias (CIBEREHD), Alcalá de Henares, Spain
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28
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Dragoi AM, Radulescu I, Năsui BA, Pop AL, Varlas VN, Trifu S. Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:E840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. OBJECTIVE to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. DATA SOURCES a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years. STUDY ELIGIBILITY CRITERIA clinical trials on adults with acute symptoms of schizophrenia or related disorders. RESULTS we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. LIMITATIONS we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Affiliation(s)
- Ana Miruna Dragoi
- Department of Psychiatry, “Alexandru Obregia” Clinical Hospital for Psychiatry, 10 Berceni St., 041914 Bucharest, Romania;
| | - Ioana Radulescu
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hațieganu” University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania; or
| | - Anca Lucia Pop
- Department of Clinical Laboratory, Food Safety, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia St., 020945 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Simona Trifu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania;
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Potkin SG, Kane JM, Correll CU, Lindenmayer JP, Agid O, Marder SR, Olfson M, Howes OD. The Neurobiology of Treatment-Resistant Schizophrenia: Paths to Antipsychotic Resistance and A Roadmap for Future Research. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:456-465. [PMID: 33343259 DOI: 10.1176/appi.focus.18309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from NPJ Schizophrenia (2020) 6:1).
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30
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Stam N, Taipale H, Tanskanen A, Isphording L, Okhuijsen‐Pfeifer C, Schuiling‐Veninga CC, Bos JH, Bijker BJ, Tiihonen J, Luykx JJ. Persistence of Antipsychotic Use After Clozapine Discontinuation: A Real-World Study Across Antipsychotics. Clin Transl Sci 2020; 13:1170-1177. [PMID: 32441836 PMCID: PMC7719358 DOI: 10.1111/cts.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023] Open
Abstract
Although clozapine treatment is often discontinued due to limited efficacy or low tolerability, there is a lack of guidelines and evidence on treatment options after discontinuation of clozapine in patients with schizophrenia. Persistence has proven to be an adequate indicator for treatment effectiveness in patients with schizophrenia. The aim of this study was, therefore, to compare persistence of antipsychotic use between antipsychotic treatment options in patients after stopping clozapine treatment. Registry data from a prescription database representative of the Dutch population (1996-2017) was collected to investigate persistence in patients with schizophrenia who had been using clozapine for ≥ 90 days. Persistence with antipsychotics after clozapine discontinuation was analyzed using Cox-proportional hazard regression models. Our study population consisted of 321 participants, of whom 138 re-initiated clozapine and 183 started some other antipsychotic in the year after clozapine discontinuation (N = 518 antipsychotic use periods, N = 9,178 months). Second-generation antipsychotics (SGAs) as a group were associated with better persistence compared to first-generation antipsychotics (adjusted hazard ratio (aHR), 0.73; 95% confidence interval (CI) 0.57-0.93; P = 0.011). Compared with other antipsychotics, the following oral monotherapy antipsychotics were associated with significantly better persistence: restarting clozapine (aHR 0.48; 95% CI 0.32-0.71; P < 0.001) and switching to risperidone (aHR 0.52; 95% CI 0.32-0.84; P = 0.008) or olanzapine (aHR 0.55; 95% CI 0.35-0.87; P = 0.010). Sensitivity analyses confirmed the results. In conclusion, oral SGAs are associated with better persistence than alternative antipsychotic treatment options in patients discontinuing clozapine for undefined reasons. Especially clozapine (except in those with previous serious adverse reactions to clozapine), olanzapine and risperidone should be considered as oral monotherapy for these patients.
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Affiliation(s)
- Noraly Stam
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Heidi Taipale
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- School of PharmacyUniversity of Eastern FinlandKuopioFinland
| | - Antti Tanskanen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- Public Health SolutionsNational Institute for Health and WelfareHelsinkiFinland
| | - Luka Isphording
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Cynthia Okhuijsen‐Pfeifer
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Catharina C.M. Schuiling‐Veninga
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Jens H.J. Bos
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Bert J. Bijker
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Jari Tiihonen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- Center for Psychiatric ResearchStockholm City CouncilStockholmSweden
| | - Jurjen J. Luykx
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- Department of Translational NeuroscienceUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- GGNet Mental HealthApeldoornThe Netherlands
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31
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Luykx JJ, Stam N, Tanskanen A, Tiihonen J, Taipale H. In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine. Br J Psychiatry 2020; 217:498-505. [PMID: 31910911 PMCID: PMC7511905 DOI: 10.1192/bjp.2019.267] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided. AIMS To compare the real-world effectiveness of antipsychotics after clozapine cessation. METHOD From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences. RESULTS Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001). CONCLUSIONS Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.
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Affiliation(s)
- Jurjen J. Luykx
- Assistant Professor, Departmentsof Psychiatry and Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University; and Department of Outpatient Psychiatry, GGNet Mental Health, The Netherlands,Correspondence: Jurjen J. Luykx.
| | - Noraly Stam
- Researcher, Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Antti Tanskanen
- Researcher, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Public Health Solutions, National Institute for Health and Welfare, Finland
| | - Jari Tiihonen
- Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Finland; and Center for Psychiatric Research, Stockholm City Council, Sweden
| | - Heidi Taipale
- Assistant Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Academy Research Fellow, Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Associate Professor, School of Pharmacy, University of Eastern Finland, Finland
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32
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Binding of clozapine to the GABA B receptor: clinical and structural insights. Mol Psychiatry 2020; 25:1910-1919. [PMID: 32203158 DOI: 10.1038/s41380-020-0709-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 12/30/2022]
Abstract
Clozapine is the gold-standard agent for treatment resistant schizophrenia but its mechanism of action remains unclear. There is emerging evidence of the potential role of the GABAB receptor in the pathogenesis of schizophrenia. It has been hypothesised that clozapine can mediate its actions via the GABAB receptor. Baclofen is currently recognised as the prototype GABAB receptor agonist. There are some potential clinical similarities between clozapine and baclofen. Indeed, baclofen has been previously proposed for use as an antipsychotic agent. Our analysis of the X-ray crystal structure of GABAB receptor along with molecular docking calculations, suggests that clozapine could directly bind to the GABAB receptor similar to that of baclofen. This finding could lead to a better understanding of the pharmacological uniqueness of clozapine, potential development of a biomarker for treatment resistant schizophrenia and the development of more targeted treatments leading to personalisation of treatment.
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33
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Jones R, MacCabe JH, Price MJ, Liu X, Upthegrove R. Effect of age on the relative efficacy of clozapine in schizophrenia. Acta Psychiatr Scand 2020; 142:109-120. [PMID: 31977065 DOI: 10.1111/acps.13156] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Early treatment of schizophrenia improves outcomes. Clozapine appears to have unique benefit when other antipsychotic medication has failed. This systematic review and meta-analysis aims to assess clozapine's superiority over alternative antipsychotic medication and examine whether earlier use is associated with additional benefit. METHOD Systematic retrieval of blinded, randomized controlled trials comparing clozapine with alternative antipsychotics in adults with schizophrenia. The effect of mean age on relative clozapine response was examined using random effects meta-regression, and multiple linear regression on available patient data. RESULTS A total of 276 studies were retrieved. Thirty-four studies were included in the meta-analysis. Clozapine was significantly more effective than alternative antipsychotics in reducing psychotic symptoms and increasing response. However, meta-regression failed to show a more significant effect in younger patients (age on effect size (total psychotic symptoms) 0.00, P = 0.79 CI -0.03 to 0.03). Individual patient data were available for two studies, the larger of which showed a significant interaction between younger age and superiority of clozapine. CONCLUSION The results support clozapine's superiority over other antipsychotics. A convincing effect of age on this effect was not demonstrated, although this was suggested in one study. In view of the age of many of the included studies, and changes in reporting practice over time, new clozapine RCTs, which include age of illness onset as well as age at trial time, would be welcome in order to provide meta-analysable data for future use.
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Affiliation(s)
- R Jones
- Institute for Mental Health, University of Birmingham, Birmingham, UK.,Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - J H MacCabe
- Department of Psychosis Studies, King's College London, and South London and Maudsley NHS Foundation Trust, London, UK
| | - M J Price
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - X Liu
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Affliated School of Medicine of South China University of Technology, Guangzhou, China
| | - R Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK.,Birmingham Early Intervention Service, Birmingham Womens and Childrens NHS trust, Birmingham, UK
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Verdoux H, Quiles C. Educational needs and psychoeducation interventions in clozapine users: a narrative review. Acta Psychiatr Scand 2020; 142:96-108. [PMID: 32266962 DOI: 10.1111/acps.13172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Increasing users' knowledge about the expected benefits and risks of clozapine may contribute to the initiation and maintenance of clozapine in persons with treatment-resistant schizophrenia (TRS). The objective was to identify the educational needs of clozapine users and the interventions aimed at addressing these needs. METHOD We systematically searched multiple electronic databases for articles: (i) exploring educational needs of clozapine users and of their relatives; and (ii) reporting educational interventions aimed at addressing these needs. Data were synthesized narratively. RESULTS A total of 30 articles published from 1990 to 2019 in 8 countries fulfilled our inclusion criteria. As most studies on educational needs (n = 18) were carried out in persons already taking clozapine, educational needs of TRS patients who were candidates for clozapine treatment are not well documented. Users' level of knowledge about clozapine was often poor, especially about adverse effects or interactions with other substances, with a poor retention of information delivered at treatment initiation. Among 12 studies reporting educational interventions in clozapine users, five provided quantitative outcomes. Their findings suggest that structured educational programmes may contribute to promote clozapine initiation and to improve users' knowledge about this drug. CONCLUSION The literature is sparse on structured educational interventions about clozapine, and only one randomized controlled trial was identified. A promising strategy emerging from this review may be staging educational interventions according to the evolving needs of persons with TRS before clozapine use, at initiation and during maintenance treatment.
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Affiliation(s)
- H Verdoux
- Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, Inserm, University of Bordeaux, Bordeaux, France.,Centre Hospitalier Charles Perrens, Bordeaux, France
| | - C Quiles
- Centre Hospitalier Charles Perrens, Bordeaux, France
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35
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Okhuijsen-Pfeifer C, Sterk AY, Horn IM, Terstappen J, Kahn RS, Luykx JJ. Demographic and clinical features as predictors of clozapine response in patients with schizophrenia spectrum disorders: A systematic review and meta-analysis. Neurosci Biobehav Rev 2020; 111:246-252. [PMID: 31982601 DOI: 10.1016/j.neubiorev.2020.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/19/2019] [Accepted: 01/18/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Clozapine (CLZ) is prescribed to (relatively) treatment-resistant patients with schizophrenia spectrum disorders. Currently, it is unknown what factors predict response to CLZ. Therefore, we performed meta-analyses to identify predictors of CLZ response, hence aiming to facilitate timely and efficient prescribing of CLZ. METHODS A systematic search was performed in 'Pubmed' and 'Embase' until 1 January 2019. Articles were eligible if they provided data on predictors of CLZ response measured demographic and clinical factors at baseline or biochemical factors at follow-up in schizophrenia spectrum disorder patients. RESULTS A total of 34 articles, total number of participants = 9386; N unique = 2094, were eligible. Factors significantly associated with better CLZ response were: lower age, lower PANSS negative score and paranoid schizophrenia subtype. CONCLUSION The results of our meta-analyses suggest that three baseline demographic and clinical features are associated with better clozapine response, i.e. relatively young age, few negative symptoms and paranoid schizophrenia subtype. These variables may be taken into account by clinicians who consider treating a specific patient with CLZ.
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Affiliation(s)
- C Okhuijsen-Pfeifer
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - A Y Sterk
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - I M Horn
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - J Terstappen
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - R S Kahn
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, 10029, New York City, New York, United States
| | - J J Luykx
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands; GGNet Mental Health, Deventerstraat 459, 7323 PT, Apeldoorn, The Netherlands; Department of Translational Neuroscience, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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36
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[Pharmacotherapy of schizophrenia]. DER NERVENARZT 2020; 91:34-42. [PMID: 31919550 DOI: 10.1007/s00115-019-00858-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Schizophrenia is a severe psychiatric disorder with variable therapeutic responses, the etiology and pathophysiology of which require further elucidation. OBJECTIVE To review which pharmacological options are effective and safe and for which treatment goals in schizophrenia. MATERIAL AND METHODS Narrative review of the pharmacological therapy of adults diagnosed with schizophrenia. RESULTS Despite heterogeneous therapeutic responses, to date only dopamine antagonists or partial agonists are approved for the treatment of schizophrenia. The efficacy of antipsychotic agents differs only gradually, with the exception of clozapine for treatment-resistant schizophrenia, whereas undesired adverse effects are more variable. Those antipsychotic agents that show gradual efficacy advantages in meta-analyses of acute and maintenance treatment (clozapine, amisulpride, olanzapine, risperidone) are also those where at least one undesired adverse effect is most severely expressed. Antipsychotic adverse effects occur in subgroups of patients and are generally tolerable or treatable, whereas the "side effect" of untreated schizophrenia affects almost all patients, including relapses, psychosocial deterioration, secondary treatment resistance and increased mortality. Therefore, in patients with a confirmed diagnosis of schizophrenia, a lifelong continuous therapy is currently most likely indicated, ideally with antipsychotic agents for which adherence is directly measurable and improved. In the case of treatment resistant clozapine is the agent of choice, followed by electroconvulsive therapy, which also has the best evidence as augmentation treatment in cases of clozapine resistance. CONCLUSION New therapeutic agents with improved efficacy and tolerability as well as effectiveness for negative symptoms and cognitive disturbance are needed.
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37
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Potkin SG, Kane JM, Correll CU, Lindenmayer JP, Agid O, Marder SR, Olfson M, Howes OD. The neurobiology of treatment-resistant schizophrenia: paths to antipsychotic resistance and a roadmap for future research. NPJ SCHIZOPHRENIA 2020; 6:1. [PMID: 31911624 PMCID: PMC6946650 DOI: 10.1038/s41537-019-0090-z] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/31/2019] [Indexed: 01/13/2023]
Abstract
Treatment-resistant schizophrenia (TRS), the persistence of positive symptoms despite ≥2 trials of adequate dose and duration of antipsychotic medication with documented adherence, is a serious clinical problem with heterogeneous presentations. TRS can vary in its onset (at the first episode of psychosis or upon relapse), in its severity, and in the response to subsequent therapeutic interventions (i.e., clozapine, electroconvulsive therapy). The heterogeneity of TRS indicates that the underlying neurobiology of TRS may differ not only from treatment-responsive schizophrenia but also among patients with TRS. Several hypotheses have been proposed for the neurobiological mechanisms underlying TRS, including dopamine supersensitivity, hyperdopaminergic and normodopaminergic subtypes, glutamate dysregulation, inflammation and oxidative stress, and serotonin dysregulation. Research supporting these hypotheses is limited in part by variations in the criteria used to define TRS, as well as by the biological and clinical heterogeneity of TRS. Clinical trial designs for new treatments should be informed by this heterogeneity, and further clinical research is needed to more clearly understand the underlying neurobiology of TRS and to optimize treatment for patients with TRS.
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Affiliation(s)
| | - John M Kane
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA
- The Zucker Hillside Hospital, Glen Oaks, NY, USA
- The Feinstein Institute for Medical Research, Psychiatric Neuroscience Center of Excellence, Manhasset, NY, USA
| | - Christoph U Correll
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA
- The Zucker Hillside Hospital, Glen Oaks, NY, USA
- The Feinstein Institute for Medical Research, Psychiatric Neuroscience Center of Excellence, Manhasset, NY, USA
- Charité Universitätsmedizin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | | | - Ofer Agid
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Stephen R Marder
- The Semel Institute for Neuroscience at UCLA, Los Angeles, CA, USA
- The VA Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Mark Olfson
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Oliver D Howes
- King's College, London, UK.
- MRC London Institute of Medical Sciences, Imperial College, London, UK.
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38
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Reid S, Bhattacharyya S. Antipsychotic treatment failure in patients with psychosis and co-morbid cannabis use: A systematic review. Psychiatry Res 2019; 280:112523. [PMID: 31450032 DOI: 10.1016/j.psychres.2019.112523] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 01/23/2023]
Abstract
Whilst the effects of cannabis preceding psychosis onset are well established, an effect post-onset is less clear. Emerging evidence suggests that cannabis use is associated with increased relapse outcomes possibly because of determinants, antipsychotic treatment failure and medication adherence, that are not mutually exclusive. Due to the paucity of literature on antipsychotic treatment failure an association with cannabis remains conjectural. This review sought to summarise current evidence regarding the effect of cannabis use on antipsychotic treatment failure among users and non-users with psychosis. Ovid databases (Embase, Journals@Ovid Full Text, OvidMEDLINE® In-Process and Other Non-Indexed Citations and PsycINFO) were searched to identify relevant articles. Seven articles met eligibility criteria. Cannabis use was associated with the following deleterious outcomes increased: odds of non-remission, prescription of unique antipsychotic medications, cumulative prescription of Clozapine and poor treatment trajectories. One study reported similar life-time, but lower past-year, rates of cannabis use in those prescribed Clozapine. Another study reported differences between groups for chlorpromazine equivalent doses for long-term Olanzapine prescription. Improved methodologies are warranted due to a lack of well-designed prospective studies and heterogeneity of key variables. There remains, despite research paucity, the need to encourage early cannabis cessation and higher-quality research to inform clinical practice.
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Affiliation(s)
- Sam Reid
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.
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40
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Pardis P, Remington G, Panda R, Lemez M, Agid O. Clozapine and tardive dyskinesia in patients with schizophrenia: A systematic review. J Psychopharmacol 2019; 33:1187-1198. [PMID: 31347436 DOI: 10.1177/0269881119862535] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is commonly recommended that a switch to clozapine be implemented in the face of tardive dyskinesia, even if current treatment involves another "atypical" agent. However, reports do indicate clozapine carries a liability for tardive dyskinesia. AIMS This review sought to evaluate clozapine in relation to tardive dyskinesia in the context of available evidence. METHODS Medline, Embase, and PsycINFO databases were searched for studies published in English, using the keywords: clozapine AND tardive dyskinesia OR TD. References from major review articles were searched for additional relevant publications. Studies were included if they investigated: tardive dyskinesia in clozapine-treated patients diagnosed with schizophrenia spectrum disorders, and reported on two or more assessments of tardive dyskinesia severity measured by the Abnormal Involuntary Movement Scale; or clozapine's tardive dyskinesia liability. RESULTS In total, 513 unique citations were identified and 29 reports met the inclusion criteria. Thirteen studies suggest clozapine reduces dyskinetic symptoms over time (n=905 clozapine-treated participants); however, the minimum required dose and effect of withdrawal requires further investigation. The majority of reports which address clozapine's liability for tardive dyskinesia are case studies (11 of 14 reports, 79%), and clozapine was only the first-line treatment in one of the remaining three studies reporting treatment-emergent dyskinetic symptoms with clozapine in 12% of patients. No significant between-drug differences were identified comparing clozapine's risk to other atypical antipsychotics. CONCLUSIONS Research to date supports switching to clozapine for the purpose of reducing tardive dyskinesia risk and/or treating existing tardive dyskinesia, but prospective randomized controlled trials are necessary if we are to substantiate existing recommendations.
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Affiliation(s)
- Parnian Pardis
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roshni Panda
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Milan Lemez
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Ofer Agid
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Leung CCY, Gadelrab R, Ntephe CU, McGuire PK, Demjaha A. Clinical Course, Neurobiology and Therapeutic Approaches to Treatment Resistant Schizophrenia. Toward an Integrated View. Front Psychiatry 2019; 10:601. [PMID: 31551822 PMCID: PMC6735262 DOI: 10.3389/fpsyt.2019.00601] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 07/29/2019] [Indexed: 12/19/2022] Open
Abstract
Despite considerable psychotherapeutic advancement since the discovery of chlorpromazine, almost one third of patients with schizophrenia remain resistant to dopamine-blocking antipsychotics, and continue to be exposed to unwanted and often disabling side effects, but little if any clinical benefit. Even clozapine, the superior antipsychotic treatment, is ineffective in approximately half of these patients. Thus treatment resistant schizophrenia (TRS), continues to present a major therapeutic challenge to psychiatry. The main impediment to finding novel treatments is the lack of understanding of precise molecular mechanisms leading to TRS. Not only has the neurobiology been enigmatic for decades, but accurate and early detection of patients who are at risk of not responding to dopaminergic blockade remains elusive. Fortunately, recent work has started to unravel some of the neurobiological mechanisms underlying treatment resistance, providing long awaited answers, at least to some extent. Here we focus on the scientific advances in the field, from the clinical course of TRS to neurobiology and available treatment options. We specifically emphasize emerging evidence from TRS imaging and genetic literature that implicates dysregulation in several neurotransmitters, particularly dopamine and glutamate, and in addition genetic and neural alterations that concertedly may lead to the formation of TRS. Finally, we integrate available findings into a putative model of TRS, which may provide a platform for future studies in a bid to open the avenues for subsequent development of effective therapeutics.
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Affiliation(s)
- Cheryl Cheuk-Yan Leung
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Romayne Gadelrab
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | | | - Philip K. McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Arsime Demjaha
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience (IoPPN), King’s College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Kokurcan A. Comparison of Clinical Characteristics Between the Patients with Schizophrenia on Clozapine Treatment with Those Taking Combination of Long-Acting Injectable and Oral Antipsychotics. Noro Psikiyatr Ars 2019; 56:219-223. [PMID: 31523150 PMCID: PMC6732814 DOI: 10.29399/npa.23548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/12/2019] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The primary aim of this study was to compare clinical characteristics between the patients with schizophrenia on clozapine treatment with those under combination of long-acting injectable and oral antipsychotics (combined treatment), and the secondary aim was to evaluate the impact of obsessive-compulsive disorder (OCD) comorbidity on the clinical variables. METHODS The patients with schizophrenia applied at Outpatient Psychiatry Clinic of the University between October 2017 and March 2018 taking clozapine or combined treatment were included in the study. The participants were administered Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions Scale, Scale for the Assessment of Positive and Negative Symptoms (SAPS/SANS), Calgary Depression Scale for Schizophrenia (CDSS), Yale-Brown Obsessive Compulsive Scale (YBOCS), Turkish version of Schedule for Assessing the three components of insight (SAI), and Global Assessment of Functioning Scale (GAF). RESULTS Patients on clozapine had higher Y-BOCS, BPRS, SANS, CDSS scores, and lower GAF scores compared to those taking combined antipsychotics (p<0.05). OCD comorbidity rate was 13% in the combination therapy group and 36% in clozapine users. The SAPS scores were higher but CDSS scores were lower in clozapine users with the presence of OCD comorbidity (p<0.05). CONCLUSION Clozapine and combined therapy groups differed widely by the clinical characteristics of the patients in this study. Both groups showed a high OCD comorbidity rate in this study and OCD comorbidity should be considered when schizophrenia treatment is initiated to obtain more satisfactory results. Furthermore, patients on clozapine seem to show a different relationship with OCD comorbidity compared to those under combined treatment.
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Affiliation(s)
- Ahmet Kokurcan
- Health Sciences University, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Psychiatry Clinic, Ankara, Turkey
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43
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Okhuijsen‐Pfeifer C, Cohen D, Bogers JPAM, de Vos CMH, Huijsman EAH, Kahn RS, Luykx JJ. Differences between physicians' and nurse practitioners' viewpoints on reasons for clozapine underprescription. Brain Behav 2019; 9:e01318. [PMID: 31144470 PMCID: PMC6625469 DOI: 10.1002/brb3.1318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Clozapine (CLZ) is the only proven effective therapy for treatment-resistant schizophrenia, but it is underutilized across the globe. Previous findings suggest a lack of experience with CLZ prescription and concerns about CLZ's pharmacological characteristics are the prime reasons for CLZ underutilization. To our knowledge, it is currently unknown whether the reasons for underutilization and suggested solutions differ between physicians and nurse practitioners. Such differences are important as nurse practitioners are becoming increasingly involved in prescribing CLZ. METHODS To examine to what degree physicians and nurse practitioners differ with regard to their take on reasons for CLZ underutilization and suggested solutions, an online questionnaire was distributed to physicians and nurse practitioners. The primary outcome was to compare the patient-related and prescriber-related reasons for CLZ underprescription between physicians and nurse practitioners, while secondary outcome measures included the potential solutions to prevent this underprescription. RESULTS Physicians (N = 112) and nurse practitioners (N = 41) agreed that the two most common reasons for underprescription (patient-related and prescriber-related) were refusal to undergo regular blood tests and side-effect concerns. They also agreed that the third most common prescriber-related reason was medical complications. Physicians rated patients' unwillingness to switch medication as the third most common reason for CLZ underprescription, whereas nurse practitioners rated refusal to undergo baseline bloodtests as the third most common reason. The solutions to reduce underprescription largely corresponded between both groups. CONCLUSIONS We conclude that slight differences exist between physicians' and nurse practitioners' viewpoints on patient-related and prescriber-related reasons for CLZ underprescription. Future research projects should involve patients to elucidate whether the patient-related factors put forward by prescribers align with the patients' opinions.
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Affiliation(s)
- Cynthia Okhuijsen‐Pfeifer
- Department of psychiatryBrain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Dan Cohen
- MHO GGZ‐NHNHeerhugowaardThe Netherlands
- Dutch Clozapine Collaboration GroupCastricumThe Netherlands
| | - Jan P. A. M. Bogers
- Dutch Clozapine Collaboration GroupCastricumThe Netherlands
- MHO Rivierduinen, High Care ClinicsOegstgeestThe Netherlands
| | - Cato M. H. de Vos
- Department of psychiatryBrain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Elianne A. H. Huijsman
- Department of psychiatryBrain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - René S. Kahn
- Department of psychiatryBrain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of PsychiatryIcahn School of Medicine at Mount SinaiNew York CityNew York
| | - Jurjen J. Luykx
- Department of psychiatryBrain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of translational neuroscienceUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- GGNet Mental HealthApeldoornThe Netherlands
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Kostev K, Osina G, Konrad M. Treatment patterns of patients with schizophrenia based on the data from 44,836 outpatients in Russia. HEART AND MIND 2019. [DOI: 10.4103/hm.hm_73_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Affiliation(s)
- P Homan
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Department of Psychiatry, The Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - J M Kane
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Department of Psychiatry, The Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
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46
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Okhuijsen‐Pfeifer C, Huijsman EAH, Hasan A, Sommer IEC, Leucht S, Kahn RS, Luykx JJ. Clozapine as a first- or second-line treatment in schizophrenia: a systematic review and meta-analysis. Acta Psychiatr Scand 2018; 138:281-288. [PMID: 30218445 PMCID: PMC6175356 DOI: 10.1111/acps.12954] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2018] [Indexed: 12/02/2022]
Abstract
OBJECTIVE No consensus exists on whether clozapine should be prescribed in early stages of psychosis. This systematic review and meta-analysis therefore focus on the use of clozapine as first-line or second-line treatment in non-treatment-resistant patients. METHODS Articles were eligible if they investigated clozapine compared to another antipsychotic as a first- or second-line treatment in non-treatment-resistant schizophrenia spectrum disorders (SCZ) patients and provided data on treatment response. We performed random-effects meta-analyses. RESULTS Fifteen articles were eligible for the systematic review (N = 314 subjects on clozapine and N = 800 on other antipsychotics). Our meta-analysis comparing clozapine to a miscellaneous group of antipsychotics revealed a significant benefit of clozapine (Hedges' g = 0.220, P = 0.026, 95% CI = 0.026-0.414), with no evidence of heterogeneity. In addition, a sensitivity analysis revealed a significant benefit of clozapine over risperidone (Hedges' g = 0.274, P = 0.030, 95% CI = 0.027-0.521). CONCLUSION The few eligible trials on this topic suggest that clozapine may be more effective than other antipsychotics when used as first- or second-line treatment. Only large clinical trials may comprehensively probe disease stage-dependent superiority of clozapine and investigate overall tolerability.
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Affiliation(s)
- C. Okhuijsen‐Pfeifer
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - E. A. H. Huijsman
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - A. Hasan
- Department of Psychiatry and PsychotherapyKlinikum der UniversitätMunichGermany
| | - I. E. C. Sommer
- Department of Neuroscience and Department of PsychiatryUniversitair Medisch Centrum GroningenGroningenThe Netherlands
| | - S. Leucht
- Department of Psychiatry and PsychotherapyTechnische Universität MünchenMunichGermany
| | - R. S. Kahn
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of PsychiatryIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - J. J. Luykx
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of Translational NeuroscienceBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of PsychiatryZNA HospitalsAntwerpBelgium,Department of PsychiatrySymforaMeander HospitalAmersfoortThe Netherlands
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