1
|
Partanen JJ, Häppölä P, Kämpe A, Ahola-Olli A, Hellsten A, Rask SM, Haaki W, Hietala J, Kampman O, Tiihonen J, Tanskanen AJ, Daly MJ, Ripatti S, Palotie A, Taipale H, Lähteenvuo M, Koskela JT. High Burden of Ileus and Pneumonia in Clozapine-Treated Individuals With Schizophrenia: A Finnish 25-Year Follow-Up Register Study. Am J Psychiatry 2024:appiajp20230744. [PMID: 39262212 DOI: 10.1176/appi.ajp.20230744] [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] [Indexed: 09/13/2024]
Abstract
OBJECTIVE The authors used longitudinal biobank data with up to 25 years of follow-up on over 2,600 clozapine users to derive reliable estimates of the real-world burden of clozapine adverse drug events (ADEs). METHODS A total of 2,659 participants in the FinnGen biobank project had a schizophrenia diagnosis and clozapine purchases with longitudinal electronic health record follow-up for up to 25 years after clozapine initiation. Diseases and health-related events enriched during clozapine use were identified, adjusting for disease severity. The incidence and recurrence of ADEs over years of clozapine use, their effect on clozapine discontinuation and deaths, and their pharmacogenetics were studied. RESULTS Median follow-up time after clozapine initiation was 12.7 years. Across 2,157 diseases and health-related events, 27 were enriched during clozapine use, falling into five disease categories: gastrointestinal hypomotility, seizures, pneumonia, other acute respiratory tract infections, and tachycardia, along with a heterogeneous group including neutropenia and type 2 diabetes, among others. Cumulative incidence estimates for ileus (severe gastrointestinal hypomotility) and pneumonia were 5.3% and 29.5%, respectively, 20 years after clozapine initiation. Both events were significantly associated with increased mortality among clozapine users (ileus: odds ratio=4.5; pneumonia: odds ratio=2.8). Decreased genotype-predicted CYP2C19 and CYP1A2 activities were associated with higher pneumonia risk. CONCLUSIONS Clozapine-induced ileus and pneumonia were notably more frequent than has previously been reported and were associated with increased mortality. Two CYP genes influenced pneumonia risk. Pneumonia and ileus call for improved utilization of available preventive measures.
Collapse
Affiliation(s)
- Juulia J Partanen
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Paavo Häppölä
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Anders Kämpe
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Ari Ahola-Olli
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Anni Hellsten
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Susanna M Rask
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Willehard Haaki
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Jarmo Hietala
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Olli Kampman
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Jari Tiihonen
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Antti J Tanskanen
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Mark J Daly
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Samuli Ripatti
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Aarno Palotie
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Heidi Taipale
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Markku Lähteenvuo
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| | - Jukka T Koskela
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (Partanen, Häppölä, Kämpe, Daly, Ripatti, Palotie, Koskela), and Faculty of Medicine (Ripatti), University of Helsinki, Helsinki; Department of Molecular Medicine and Surgery (Kämpe) and Department of Clinical Neuroscience (Tiihonen, Tanskanen, Taipale), Karolinska Institutet, Stockholm; Department of Internal Medicine (Ahola-Olli) and Department of Psychiatry (Haaki, Hietala), Turku University Hospital, Turku, Finland; Aurora Hospital, City of Helsinki, Helsinki (Hellsten); Department of Psychiatry, Faculty of Medicine and Health Technology (Rask), and Faculty of Medicine and Health Technology (Kampman), Tampere University, Tampere, Finland; Department of Psychiatry, Tampere University Hospital, Tampere, Finland (Rask); Department of Psychiatry, University of Turku, Turku, Finland (Haaki, Hietala); Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden (Kampman); Department of Clinical Medicine, Psychiatry, Faculty of Medicine, University of Turku, Turku, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Ostrobothnia, Vaasa, Finland (Kampman); Department of Psychiatry, Wellbeing Services County of Pirkanmaa, Tampere, Finland (Kampman); Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Tiihonen, Tanskanen, Taipale, Lähteenvuo); Center for Psychiatry Research, Stockholm City Council, Stockholm (Tiihonen); Stanley Center for Psychiatric Research (Daly, Palotie) and Program in Medical and Population Genetics (Daly, Ripatti, Palotie), Broad Institute of Harvard and MIT, Cambridge, MA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston (Daly, Ripatti, Palotie)
| |
Collapse
|
2
|
de Leon J, Ruan CJ, Schoretsanitis G, Villasante-Tezanos AG, Spina E, Sanz EJ, Betancort M, De Las Cuevas C. Investigating in VigiBase over 6000 cases of pneumonia in clozapine-treated patients in the context of the literature: focus on high lethality and the association with aspiration pneumonia. Expert Opin Drug Metab Toxicol 2024:1-15. [PMID: 38920369 DOI: 10.1080/17425255.2024.2373111] [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: 04/03/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND The literature associates clozapine with pneumonia/aspiration pneumonia. RESEARCH DESIGN AND METHODS The international pharmacovigilance database (VigiBase™) uses the information component (IC) as statistical signal. VigiBase clozapine reports were analyzed for pneumonia/aspiration pneumonia from introduction to 10 May 2023. RESULTS There were 6392 cases of all types of pneumonia (5572 cases of pneumonia, 775 of aspiration pneumonia, and 45 combined). The IC was 3.52 for aspiration pneumonia, introduced as a VigiBase label in 2003, and 1.91 for pneumonia. Patients were reclassified as 3628 with no signs of aspiration and 1533 with signs. Signs of aspiration were strongly associated with some co-medications: olanzapine, odds ratio (OR) = 23.8, 95% confidence interval (CI), 14.9-38.0; risperidone OR = 18.6, CI, 11.4-30.4; valproic acid, OR = 5.5, CI, 4.5-6.6; and benzodiazepines OR = 5.5, CI, 4.5-6.6. In 2415 cases with completed data, fatal outcomes made up 45% (signs of aspiration made no difference), but there was wide variability from 0% (females <45 years of age; duration ≤30 days) to 76% (males >64 years of age; duration >1 year). During the first week, pneumonia was associated with 1) very high titration doses, 2) very small doses in Parkinson's disease, and 3) Japan vs other countries. CONCLUSIONS In clozapine-treated patients: 1) at least 30% of pneumonia cases may be aspiration pneumonia, 2) stopping some co-medications may decrease the risk of aspiration pneumonia, 3) average lethality in pneumonia was 45% but may be around 75% in geriatric patients with long-term treatment, and 4) safer titrations may sometimes require 5-mg tablets.
Collapse
Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, La Laguna, Canary Islands, Spain
| | - Moisés Betancort
- Department of Clinical Psychology, Psychobiology, and Methodology, Universidad de La Laguna, La Laguna, Canary Islands, Spain
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Canary Islands, Spain
| |
Collapse
|
3
|
De Las Cuevas C, Sanz EJ, Gross JA, Correll CU, Verdoux H, Lally J, de Filippis R, Schulte PFJ, Molden E, Arrojo-Romero M, Bostrom AD, Schoretsanitis G, Fernandez-Egea E, de Leon J. Revealing the reporting disparity: VigiBase highlights underreporting of clozapine in other Western European countries compared to the UK. Schizophr Res 2024; 268:175-188. [PMID: 38065799 DOI: 10.1016/j.schres.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 06/15/2024]
Abstract
BACKGROUND Pharmacovigilance studies indicate clozapine history is marked by adverse drug reactions (ADRs). OBJECTIVE In a 2021 article, the United Kingdom (UK) had >90 % of European clozapine-related fatal outcomes in VigiBase, the World Health Organization's pharmacovigilance database. Two possibly opposing hypotheses could explain this disparity: 1) fewer reported fatal outcomes in other Western European countries mainly reflect underreporting to VigiBase, and 2) the higher number of UK reports reflects higher real relative mortality. METHODS VigiBase reports from clozapine's introduction to December 31, 2022, were studied for ADRs and the top 10 causes of fatal outcomes. The UK was compared with 11 other top reporting Western countries (Germany, Denmark, France, Finland, Ireland, Italy, Netherlands, Norway, Spain, Sweden and Switzerland). Nine countries (except Ireland and Switzerland) were compared after controlling for population and clozapine prescriptions. RESULTS The UK accounted for 29 % of worldwide clozapine-related fatal outcomes, Germany 2 % and <1 % in each of the other countries. The nonspecific label "death" was the top cause in the world (46 %) and in the UK (33 %). "Pneumonia" was second in the world (8 %), the UK (12 %), Ireland (8 %) and Finland (14 %). Assuming that our corrections for population and clozapine use are correct, other countries underreported only 1-10 % of the UK clozapine fatal outcome number. CONCLUSIONS Different Western European countries consistently underreport to VigiBase compared to the UK, but have different reporting/publishing styles for clozapine-related ADRs/fatal outcomes. Three Scandinavian registries suggest lives are saved as clozapine use increases, but this cannot be studied in pharmacovigilance databases.
Collapse
Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France.
| | - John Lally
- Department of Psychiatry, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.; Department of Psychiatry, St Vincent's Hospital Fairview, Dublin, Ireland; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain.
| | - Adrian D Bostrom
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden.
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK,; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
| |
Collapse
|
4
|
Smessaert S, Detraux J, Desplenter F, De Hert M. Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review. CNS Drugs 2024; 38:105-123. [PMID: 38236524 DOI: 10.1007/s40263-023-01054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects. METHODS A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality. RESULTS Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%). CONCLUSIONS Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines. REGISTRATION PROSPERO registration number, CRD42023402480.
Collapse
Affiliation(s)
- Sarah Smessaert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium.
| | - Johan Detraux
- Department of Biomedical Sciences, Research Group Psychiatry, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
| | - Franciska Desplenter
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Marc De Hert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
5
|
Berger SJ, Hofer A. [Safety aspects during treatment with clozapine: : Adverse effects, titration, and therapeutic drug monitoring - a narrative review]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2023; 37:122-129. [PMID: 37349671 PMCID: PMC10491532 DOI: 10.1007/s40211-023-00474-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/19/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND According to current guidelines, clozapine should be used as a third step in treatment resistant schizophrenia (TRS). In everyday clinical practice, however, it is frequently used at a much later stage, which leads to a significant deterioration of prognosis. The first part of this narrative overview focuses on the most frequent side effects of clozapine, on the relevance of slow titration, and on specific aspects of therapeutic drug monitoring (TDM). MATERIAL AND METHODS Medline, the Guideline for the use of clozapine 2013 of the Netherlands Clozapine Collaboration Group, and the S3 Guideline for Schizophrenia of the German Association for Psychiatry, Psychotherapy and Psychosomatics were searched for relevant literature, the last query dating from April 28th, 2023. RESULTS Despite its unique efficacy clozapine is underused in clinical practice and prescription varies between and within countries. Next to hematological, metabolic, and vegetative side effects, clozapine induced inflammation manifesting in the form of pneumonia or myocarditis, which is mainly associated with rapid titration, represents a major clinical challenge with CRP monitoring being of particular relevance. In this context, it also has to be noted that sex, smoking behavior, and ethnic origin impact clozapine metabolism, thus requiring personalized dosing. CONCLUSION Slow titration when possible, TDM, and CYP diagnostics when appropriate increase patient safety during treatment with clozapine and thus the likelihood of early prescription of this compound in TRS.
Collapse
Affiliation(s)
- Stefan J Berger
- Department für Psychiatrie, Psychotherapie, Psychosomatik und Medizinische Psychologie, Univ.-Klinik für Psychiatrie I, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Alex Hofer
- Department für Psychiatrie, Psychotherapie, Psychosomatik und Medizinische Psychologie, Univ.-Klinik für Psychiatrie I, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
| |
Collapse
|
6
|
de Leon J, Arrojo-Romero M, Verdoux H, Ruan CJ, Schoretsanitis G, Rohde C, Cohen D, Schulte PFJ, Kim SH, Cotes RO, Leung JG, Otsuka Y, Kirilochev OO, Baptista T, Grover S, Every-Palmer S, Clark SR, McGrane IR, Motuca M, Olmos I, Wilkowska A, Sagud M, Anıl Yağcıoğlu AE, Ristic DI, Lazary J, Sanz EJ, De Las Cuevas C. Escaping the Long Shadow Cast by Agranulocytosis: Reflections on Clozapine Pharmacovigilance Focused on the United Kingdom. J Clin Psychopharmacol 2023; 43:239-245. [PMID: 37068034 DOI: 10.1097/jcp.0000000000001678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
PURPOSE/BACKGROUND A recent article in this journal presented a US perspective regarding the modernization of clozapine prescription and proposed an escape from the long shadow cast by agranulocytosis. METHODS Here, an international group of collaborators discusses a point of view complementary to the US view by focusing on worldwide outcomes of clozapine usage that may be uneven in terms of frequency of clozapine adverse drug reactions. FINDINGS/RESULTS Studies from the Scandinavian national registries (Finland and Denmark) did not find increased mortality in clozapine patients or any clear evidence of the alleged toxicity of clozapine. Data on clozapine-associated fatal outcomes were obtained from 2 recently published pharmacovigilance studies and from the UK pharmacovigilance database. A pharmacovigilance study focused on physician reports to assess worldwide lethality of drugs from 2010 to 2019 found 968 clozapine-associated fatal outcomes in the United Kingdom. Moreover, the United Kingdom accounted for 55% (968 of 1761) of worldwide and 90% (968 of 1073) of European fatal clozapine-associated outcomes. In a pharmacovigilance study from the UK database (from 2008 to 2017), clozapine was associated with 383 fatal outcomes/year including all reports from physicians and nonphysicians. From 2018 to 2021, UK clozapine-associated fatal outcomes increased to 440/year. IMPLICATIONS/CONCLUSIONS The interpretation of fatal outcomes in each country using pharmacovigilance databases is limited and only allows gross comparisons; even with those limitations, the UK data seem concerning. Pneumonia and myocarditis may be more important than agranulocytosis in explaining the uneven distribution of fatal outcomes in clozapine patients across countries.
Collapse
Affiliation(s)
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | | | | | | | | | | | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | | | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Chiba, Japan
| | - Oleg O Kirilochev
- Department of Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Russian Federation
| | | | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Scott R Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, South Australia, Australia
| | - Ian R McGrane
- Department of Pharmacy Practice, University of Montana, Missoula, MT
| | - Mariano Motuca
- Instituto Vilapriño, Center for Studies, Assistance and Research in Neurosciences, Mendoza, Argentina
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | | | - Judit Lazary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | | | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Canary Islands, Spain
| |
Collapse
|
7
|
De Las Cuevas C, Sanz EJ, Villasante-Tezanos AG, de Leon J. Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in VigiBase. Expert Opin Drug Metab Toxicol 2023; 19:57-74. [PMID: 36920343 DOI: 10.1080/17425255.2023.2192401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Antipsychotics (APs), during treatment or overdose, may be associated with respiratory aspiration. AREAS COVERED A PubMed search on September 30, 2022, provided 3 cases of respiratory aspiration during clozapine therapy and 1 case during an AP overdose. VigiBase records of respiratory aspiration associated with APs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC). EXPERT OPINION The ICs (and IC025) were 2.1 (and 2.0) for APs, 3.2 (and 3.0) for clozapine, 2.6 (and 2.4) for quetiapine, and 2.5 (and 2.2) for olanzapine. Cases of respiratory aspiration associated with APs included: 137 overdose/suicide cases (64 fatal) and 609 cases during treatment (385 fatal) including 333 taking clozapine (238 fatal). In logistic regression models of fatal outcomes, the odds ratios, OR, and (95% confidence intervals, CI) of significant independent variables were: a) 2.3 - 2.6 for clozapine in 3 samples of AP treatment of varying size, b) 1.9 (CI 1.0 to 3.5) for geriatric age in 284 patients on clozapine treatment, and c) 1.8 (CI 1.1 - 3.2) for antidepressant co-medication in 276 patients on non-clozapine APs. Multiple AP pharmacological mechanisms may explain respiratory aspiration.
Collapse
Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain.,Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Alejandro G Villasante-Tezanos
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, United States
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, United States.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| |
Collapse
|
8
|
Copeland CS, Wallman P, Morgan D, Owen E, Taylor D. A case-control study of antipsychotic use and pneumonia-related mortality in the United Kingdom. Acta Psychiatr Scand 2023; 147:301-313. [PMID: 36651563 DOI: 10.1111/acps.13532] [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: 08/25/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIM There is increasing evidence linking antipsychotic use with pneumonia, but limited evidence of an effect on pneumonia-related outcomes such as mortality. In this study, we aimed to examine the association of pneumonia-related death with specific antipsychotic exposure. METHOD Deaths analysed were those reported to a UK-based drug-related deaths database, the National Programme on Substance Abuse Deaths (NPSAD), between 1997 and September 2020. We conducted a case-control study with cases defined as pneumonia-related deaths and controls as cases with alternative causes of death. Cases were analysed by considering drugs detected at post-mortem (PM) and by drugs prescribed to the deceased at the time of their death with calculated odds ratios (ORs) adjusted to account for confounders. RESULTS There were 2467 PM cases and 40,128 controls; 1818 prescribed cases and 28,018 controls. Second generation antipsychotics (SGAs) were robustly associated with an increased risk of pneumonia-related death compared with those not prescribed or taking antipsychotics (PM detection adjusted OR [AOR] 1·34 [95% CI 1·15-1·55]; prescribed AOR 1·28 [95% CI 1·11-1·49]). First generation antipsychotics had no clear association with death from pneumonia (PM detection AOR 1·06 [95% CI 0·77-1·47]; prescribed AOR 0·91 [95% CI 0·71-1·17]). Amongst SGAs, olanzapine was associated with an increased risk of death due to pneumonia (PM detection AOR 1·49 [95% CI 1·22-1·82]; prescribed AOR 1·44 [95% CI 1·18-1·76]) as was quetiapine (PM detection AOR 1·34 [95% CI 1·07-1·66]; prescribed AOR 1·28 [95% CI 1·01-1·64]). CONCLUSION Olanzapine and quetiapine were found to increase the risk of pneumonia-related death in this NPSAD sample to a clinically important extent.
Collapse
Affiliation(s)
- Caroline S Copeland
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Centre for Pharmaceutical Medicine Research, King's College London, London, UK
| | - Phoebe Wallman
- Divisons of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Morgan
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Centre for Pharmaceutical Medicine Research, King's College London, London, UK
| | - Eleanor Owen
- Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - David Taylor
- Institute of Pharmaceutical Sciences, King's College London, London, UK.,Divisons of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
9
|
de Leon J, Schoretsanitis G, Smith RL, Molden E, Solismaa A, Seppälä N, Kopeček M, Švancer P, Olmos I, Ricciardi C, Iglesias-Garcia C, Iglesias-Alonso A, Spina E, Ruan CJ, Wang CY, Wang G, Tang YL, Lin SK, Lane HY, Kim YS, Kim SH, Rajkumar AP, González-Esquivel DF, Jung-Cook H, Baptista T, Rohde C, Nielsen J, Verdoux H, Quiles C, Sanz EJ, Las Cuevas CD, Cohen D, Schulte PFJ, Ertuğrul A, Yağcıoğlu AEA, Chopra N, McCollum B, Shelton C, Cotes RO, Kaithi AR, Kane JM, Farooq S, Ng CH, Bilbily J, Hiemke C, López-Jaramillo C, McGrane I, Lana F, Eap CB, Arrojo-Romero M, Rădulescu FŞ, Seifritz E, Every-Palmer S, Bousman CA, Bebawi E, Bhattacharya R, Kelly DL, Otsuka Y, Lazary J, Torres R, Yecora A, Motuca M, Chan SKW, Zolezzi M, Ouanes S, Berardis DD, Grover S, Procyshyn RM, Adebayo RA, Kirilochev OO, Soloviev A, Fountoulakis KN, Wilkowska A, Cubała WJ, Ayub M, Silva A, Bonelli RM, Villagrán-Moreno JM, Crespo-Facorro B, Temmingh H, Decloedt E, Pedro MR, Takeuchi H, Tsukahara M, Gründer G, Sagud M, Celofiga A, Ristic DI, Ortiz BB, Elkis H, Pacheco Palha AJ, LLerena A, Fernandez-Egea E, Siskind D, Weizman A, Masmoudi R, Saffian SM, Leung JG, Buckley PF, Marder SR, Citrome L, Freudenreich O, Correll CU, Müller DJ. An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels. PHARMACOPSYCHIATRY 2021; 55:73-86. [PMID: 34911124 DOI: 10.1055/a-1625-6388] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.
Collapse
Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA.,Department of Psychiatry, University of Kentucky, Lexington, KY, USA.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - Robert L Smith
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Anssi Solismaa
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Psychiatry, Tampere University Hospital, Tampere, Finland
| | | | - Miloslav Kopeček
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Patrik Švancer
- National Institute of Mental Health, Klecany, Czech Republic.,Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Carina Ricciardi
- Clinical Pharmacology Unit and Outpatient Clinic, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Celso Iglesias-Garcia
- Universidad de Oviedo. CIBERSAM. INEUROPA. ISPA-FIMBA, Oviedo, Spain.,Hospital Valle del Nalón, Langreo, Spain
| | | | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Chuan-Yue Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China.,Department of Psychiatry, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Gang Wang
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Substance Abuse Treatment Program, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Shih-Ku Lin
- Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan.,Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Yong Sik Kim
- Department of Neuropsychiatry, Nowon Eulji Medical Center, Eulji University, School of Medicine, Seoul, Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Anto P Rajkumar
- Department of Psychiatry, Christian Medical College, Vellore, India.,Institute of Mental Health, Jubilee Campus, University of Nottingham, Triumph Road, Nottingham, United Kingdom
| | | | - Helgi Jung-Cook
- Instituto Nacional de Neurología y Neurocirugía, México City, México.,Facultad de Química, Universidad Nacional Autónoma de México (UNAM), México City, México
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jimmi Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Clelia Quiles
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, and Instituto Universitario de Neurociencia (IUNE), University of La Laguna, Canary Islands, Spain
| | - Dan Cohen
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,FACT-team in Heerhugowaard, Department of Severe Mental Illness, Mental Health Services North-Holland North, The Netherlands
| | - Peter F J Schulte
- Dutch Clozapine Collaboration Group, Castricum, The Netherlands.,Mental Health Team Alkmaar, Mental Health Services Noord-Holland-Noord, Alkmaar, The Netherlands
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Nitin Chopra
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Charles Shelton
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA.,Eastern State Hospital, Lexington, Kentucky, USA
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA
| | - Saeed Farooq
- School of Medicine, Keele University, Staffordshire, and Midlands Partnership NHS Foundation Trust, Staffordshire, United Kingdom
| | - Chee H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Bilbily
- Department of Psychiatry, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Germany
| | - Carlos López-Jaramillo
- Grupo de Investigación en Psiquiatría GIPSI, Departamento de Psiquiatría, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia.,Programa Trastornos del Ánimo, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Ian McGrane
- Department of Pharmacy Practice, University of Montana, Missoula, USA
| | - Fernando Lana
- Institute of Neuropsychiatry and Addictions (INAD), Parc de Salut Mar, Barcelona, Spain.,Department of Psychiatry, Autonomous University of Barcelona, Spain
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Flavian Ş Rădulescu
- Center for Drug Sciences, Faculty of Pharmacy, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Susanna Every-Palmer
- Te Korowai Whāriki Central Regional Forensic Service, Capital and Coast District Health Board, Wellington, New Zealand.,Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Chad A Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, and Community Health Sciences University of Calgary, Alberta, Canada
| | - Emmanuel Bebawi
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Rahul Bhattacharya
- East London NHS Foundation Trust, London, United Kingdom.,Honorary Clinical Senior Lecturer, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Deanna L Kelly
- Department of Psychiatry, School of Medicine, Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Chiba, Japan
| | - Judit Lazary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | - Rafael Torres
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Agustin Yecora
- Secretaría de Salud Mental y Adicciones, Ministerio de Salud de la Provincia de Jujuy, San Salvador de Jujuy, Argentina
| | - Mariano Motuca
- Instituto Vilapriño, Center for Studies, Assistance and Research in Neurosciences, Mendoza, Argentina
| | - Sherry K W Chan
- Department of Psychiatry, LSK Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
| | - Monica Zolezzi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Sami Ouanes
- Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | | | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ric M Procyshyn
- British Columbia Mental Health and Substance Use Research Institute, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Oleg O Kirilochev
- Department of Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Russian Federation
| | - Andrey Soloviev
- Department of Psychiatry and Clinical Psychology, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Division of Neurosciences, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Wiesław J Cubała
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Muhammad Ayub
- Department of Psychiatry, Queens University, Kingston, Canada
| | - Alzira Silva
- Psychiatry Department, Centro Hospitalar Universitário de S. João, Porto, Portugal., Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - José M Villagrán-Moreno
- Department of Neurosciences, Jerez University Hospital, Andalusian Health Service, University of Cadiz, Jerez, Spain
| | - Benedicto Crespo-Facorro
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocio-IBIS, Sevilla, Spain., Spanish Network for Research in Mental Health (CIBERSAM), Sevilla, Spain
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Western Cape, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Tsukahara
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Gerhard Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marina Sagud
- Department of Psychiatry, School of Medicine, University of Zagreb, Zagreb, Croatia.,Department for Psychiatry and Psychological Medicine, University Hospital Center Zagreb, Croatia
| | - Andreja Celofiga
- Department of Psychiatry, University Medical Centre Maribor, Maribor, Slovenia
| | | | - Bruno B Ortiz
- Group of Resistant Schizophrenia (GER), Schizophrenia Program (Proesq), Federal University of Sao Paulo, SP, Brazil
| | - Helio Elkis
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Sao Paulo, Brazil
| | - António J Pacheco Palha
- Department and Institute of Psychiatry and Mental Health, Oporto Faculty of Medicine, Oporto, Portugal.,Casa de Salidedo Som Jesus (Psychiatric Hospital), Oporto, Portugal
| | - Adrián LLerena
- INUBE Biosanitary Research Institute of Extremadura. Extremadura University Hospital and Medical School, Badajoz, Spain.,Spanish Network for Research in Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambrigeshire and Peterborough NHS Foundation Trust & Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, Australia.,Queensland Centre for Mental Health Research and School of Clinical Medicine, University of Queensland, Brisbane, Australia
| | - Abraham Weizman
- Research Unit, Geha Mental Health Center and Molecular Psychiatry Laboratory, Felsenstein Medical Research Center, Tel Aviv, Israel.,Department of Psychiatry Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Rim Masmoudi
- Psychiatry "A" Department, Hedi Chaker University Hospital, Sfax, Tunisia.,Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Peter F Buckley
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen R Marder
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA, USA.,VA Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Leslie Citrome
- New York Medical College, Department of Psychiatry and Behavioral Sciences, Valhalla, NY, USA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York, USA.,Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Daniel J Müller
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Cepaityte D, Siafis S, Egberts T, Leucht S, Kouvelas D, Papazisis G. Exploring a Safety Signal of Antipsychotic-Associated Pneumonia: A Pharmacovigilance-Pharmacodynamic Study. Schizophr Bull 2021; 47:672-681. [PMID: 33289848 PMCID: PMC8084433 DOI: 10.1093/schbul/sbaa163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An association between antipsychotic drugs and pneumonia has been demonstrated in several studies; however, the risk for pneumonia caused by specific antipsychotics has not been extensively studied. The underlying mechanism is still unknown, and several receptor mechanisms have been proposed. Therefore, using a combined pharmacovigilance-pharmacodynamic approach, we aimed to investigate safety signals of US Food and Drug Administration (FDA)-approved antipsychotics for reporting pneumonia and the potential receptor mechanisms involved. A disproportionality analysis was performed to detect a signal for reporting "infective-pneumonia" and "pneumonia-aspiration" and antipsychotics using reports submitted between 2004 and 2019 to the FDA adverse events spontaneous reporting system (FAERS) database. Disproportionality was estimated using the crude and the adjusted reporting odds ratio (aROR) and its 95% confidence interval (CI) in a multivariable logistic regression. Linear regressions investigated the relationship between aROR and receptor occupancy, which was estimated using in vitro receptor-binding profiles. Safety signals for reporting infective-pneumonia were identified for clozapine (LL = 95% 3.4, n = 546 [aROR: 4.8]) as well as olanzapine (LL = 95% 1.5, n = 250 [aROR: 2.1]) compared with haloperidol, while aRORs were associated with higher occupancies of muscarinic receptors (beta = .125, P-value = .016), yet other anti-muscarinic drugs were not included as potential confounders. No safety signals for reporting pneumonia-aspiration were detected for individual antipsychotics. Multiple antipsychotic use was associated with both reporting infective-pneumonia (LL 95%: 1.1, n = 369 [aROR:1.2]) and pneumonia-aspiration (LL 95%: 1.7, n = 194 [aROR: 2.0]). Considering the limitations of disproportionality analysis, further pharmacovigilance data and clinical causality assessment are needed to validate this safety signal.
Collapse
Affiliation(s)
- Dainora Cepaityte
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyridon Siafis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Toine Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Division of Pharmacoepidemiology and Clinical Pharmacology, The Netherlands & Utrecht Institute of Pharmaceutical Science, Faculty of Science, Utrecht University, The Netherlands
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dimitrios Kouvelas
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Papazisis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
11
|
Schoretsanitis G, Ruan CJ, Rohde C, Verdoux H, De Las Cuevas C, Spina E, de Leon J. An update on the complex relationship between clozapine and pneumonia. Expert Rev Clin Pharmacol 2021; 14:145-149. [PMID: 33461363 DOI: 10.1080/17512433.2021.1877135] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hélène Verdoux
- Team Pharmacoepidemiology, University Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of la Laguna, Canary Islands, Spain
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| |
Collapse
|
12
|
Okada M, Fukuyama K, Shiroyama T, Murata M. A Working Hypothesis Regarding Identical Pathomechanisms between Clinical Efficacy and Adverse Reaction of Clozapine via the Activation of Connexin43. Int J Mol Sci 2020; 21:ijms21197019. [PMID: 32987640 PMCID: PMC7583770 DOI: 10.3390/ijms21197019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Clozapine (CLZ) is an approved antipsychotic agent for the medication of treatment-resistant schizophrenia but is also well known as one of the most toxic antipsychotics. Recently, the World Health Organization’s (WHO) global database (VigiBase) reported the relative lethality of severe adverse reactions of CLZ. Agranulocytosis is the most famous adverse CLZ reaction but is of lesser lethality compared with the other adverse drug reactions of CLZ. Unexpectedly, VigiBase indicated that the prevalence and relative lethality of pneumonia, cardiotoxicity, and seizures associated with CLZ were more serious than that of agranulocytosis. Therefore, haematological monitoring in CLZ patients monitoring system provided success in the prevention of lethal adverse events from CLZ-induced agranulocytosis. Hereafter, psychiatrists must amend the CLZ patients monitoring system to protect patients with treatment-resistant schizophrenia from severe adverse CLZ reactions, such as pneumonia, cardiotoxicity, and seizures, according to the clinical evidence and pathophysiology. In this review, we discuss the mechanisms of clinical efficacy and the adverse reactions of CLZ based on the accumulating pharmacodynamic findings of CLZ, including tripartite synaptic transmission, and we propose suggestions for amending the monitoring and medication of adverse CLZ reactions associated with pneumonia, cardiotoxicity, and seizures.
Collapse
Affiliation(s)
- Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
- Correspondence: ; Tel.: +81-59-231-5018
| | - Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Takashi Shiroyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Masahiko Murata
- National Hospital Organization Sakakibara Hospital, 777 Sakakibara, Tsu, Mie 514-1292, Japan;
| |
Collapse
|
13
|
Affiliation(s)
- P F J Schulte
- Mental Health Service Noord-Holland-Noord, Heerhugowaard, The Netherlands.,Dutch Clozapine Collaboration Group, Alkmaar, The Netherlands
| | - J Bogers
- Dutch Clozapine Collaboration Group, Alkmaar, The Netherlands.,Mental Health Service Rivierduinen, Leiden, The Netherlands
| | - S R T Bond-Veerman
- Mental Health Service Noord-Holland-Noord, Heerhugowaard, The Netherlands.,Dutch Clozapine Collaboration Group, Alkmaar, The Netherlands
| | - D Cohen
- Mental Health Service Noord-Holland-Noord, Heerhugowaard, The Netherlands.,Dutch Clozapine Collaboration Group, Alkmaar, The Netherlands
| |
Collapse
|
14
|
Villasante-Tezanos AG, Rohde C, Nielsen J, de Leon J. Pneumonia risk: approximately one-third is due to clozapine and two-thirds is due to treatment-resistant schizophrenia. Acta Psychiatr Scand 2020; 142:66-67. [PMID: 32415875 DOI: 10.1111/acps.13184] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2020] [Indexed: 12/16/2022]
Affiliation(s)
| | - C Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - J Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - J de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
| |
Collapse
|
15
|
Ben Dhia A, Hamzaoui S, Mouaffak F. [Clozapine prescription in the wake of the coronavirus (SARS CoV-2) outbreak: What measures? Why?]. Encephale 2020; 46:S123-S124. [PMID: 32317164 PMCID: PMC7166252 DOI: 10.1016/j.encep.2020.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
- A Ben Dhia
- Pôle 93G04 de Psychiatrie d'Adultes; EPS Ville Evrard. 5 rue du Dr Delafontaine 93200, Saint Denis, France
| | - S Hamzaoui
- Pôle 93G04 de Psychiatrie d'Adultes; EPS Ville Evrard. 5 rue du Dr Delafontaine 93200, Saint Denis, France
| | - F Mouaffak
- Pôle 93G04 de Psychiatrie d'Adultes; EPS Ville Evrard. 5 rue du Dr Delafontaine 93200, Saint Denis, France.
| |
Collapse
|
16
|
de Leon J, Ruan CJ, Verdoux H, Wang C. Clozapine is strongly associated with the risk of pneumonia and inflammation. Gen Psychiatr 2020; 33:e100183. [PMID: 32420521 PMCID: PMC7199914 DOI: 10.1136/gpsych-2019-100183] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 12/16/2022] Open
Abstract
Clinicians need to remember that (1) systemic inflammations can increase clozapine level; (2) clozapine, by itself, can cause inflammation, particularly during titration that is too rapid for that patient; (3) clozapine may increase the risk of infection; and (4) more specifically, clozapine may be particularly strongly associated with the risk of pneumonia. Pneumonia appears to be associated with high mortality in clozapine patients around the world. Clinicians who are alert to the risk of pneumonia in clozapine patients may significantly decrease mortality in clozapine patients. There is no data on COVID-19 infections in clozapine patients, but based on what we know about clozapine pharmacology, we can hypothesise that clozapine, possibly by impairing immunological mechanisms, may increase the risk of pneumonia in infected patients. More importantly, once fever and/or pneumonia develops, the clozapine dose should be cut in half to decrease the risk of clozapine intoxication. If there is any doubt that in spite of halving the dose there are still signs of clozapine intoxication, completely stopping clozapine may be indicated. Once the signs of inflammation and fever have disappeared, the clozapine dose can be increased to the prior dosage level.
Collapse
Affiliation(s)
- Jose de Leon
- University of Kentucky Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA
| | - Can-Jun Ruan
- Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing, China
| | - Hélène Verdoux
- Inserm, Bordeaux Population Health Research Center, University of Bordeaux Faculty of Medical Sciences, Bordeaux, Aquitaine, France
| | - Chuanyue Wang
- Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing, China
| |
Collapse
|
17
|
de Leon J, Ruan CJ, Schoretsanitis G, De las Cuevas C. A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:200-214. [PMID: 32289791 PMCID: PMC7206357 DOI: 10.1159/000507638] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.
Collapse
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, USA, .,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain, .,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain,
| | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders, Beijing Key Laboratory of Mental Disorders, and Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Spain
| |
Collapse
|