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de Leon J. Can Slow Personalized Titration Using C-Reactive Protein Monitoring Decrease the High Rates and Mortality of Clozapine-Associated Myocarditis Seen in Some Countries? A Call for Research. J Clin Psychopharmacol 2024; 44:212-219. [PMID: 38595145 DOI: 10.1097/jcp.0000000000001843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
PURPOSE/BACKGROUND The hypothesis that slower personalized titration may prevent clozapine-associated myocarditis and decrease the disproportion incidence of 3% found in Australia was not described in a recent Australian article in this journal. METHODS Six countries in addition to Australia have published information suggesting a similar incidence of clozapine-associated myocarditis. On September 19, 2023, PubMed searches were updated for articles from the United States, Korea, Japan, Canada, New Zealand, and Turkey. FINDINGS/RESULTS An incidence of 3.5% (4/76) was found in a US hospital, but US experts were the first to propose that clozapine-associated myocarditis may be a hypersensitivity reaction associated with rapid titration and possibly preventable. Koreans and Japanese are of Asian ancestry and need lower minimum therapeutic doses for clozapine than patients of European ancestry. A 0.1% (2/1408) incidence of myocarditis during clozapine titration was found in a Korean hospital, but pneumonia incidence was 3.7% (52/1408). In 7 Japanese hospitals, 34% (37/110) of cases of clozapine-associated inflammation were found during faster titrations (based on the official Japanese titration) versus 13% (17/131) during slower titrations (based on the international titration guideline for average Asian patients). Recent limited studies from Canada, New Zealand, and Turkey suggest that slower personalized titration considering ancestry may help prevent clozapine-associated myocarditis. IMPLICATIONS/CONCLUSIONS Other countries have very limited published data on clozapine-associated myocarditis. Based on a recent Australian case series and these non-Australian studies, the author proposes that Australia (and other countries) should use slow personalized titration for clozapine based on ancestry and c-reactive protein monitoring.
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Kikuchi Y, Tanifuji H, Ueno S, Onuma Y, Goto M, Ishihara M, Toraiwa T, Komatsu H, Tomita H. Patterns of C-reactive protein trends during clozapine titration and the onset of clozapine-induced inflammation: a case series of weekly and daily C-reactive protein monitoring. Front Psychiatry 2024; 15:1366621. [PMID: 38449505 PMCID: PMC10914995 DOI: 10.3389/fpsyt.2024.1366621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/07/2024] [Indexed: 03/08/2024] Open
Abstract
Background International guidelines for clozapine titration recommend measuring C-reactive protein (CRP) weekly for 4 weeks after clozapine initiation to prevent fatal inflammatory adverse events, including myocarditis. However, limited evidence exists regarding whether weekly CRP monitoring can prevent clozapine-induced inflammation. Aims We examined the relationship between CRP trends and the development of clozapine-induced inflammation. We also explored the usefulness and limitations of CRP monitoring during clozapine titration. Method This study presents 17 and 4 cases of weekly and daily CRP monitoring during clozapine initiation, respectively. Results Among 17 patients with weekly CRP measurements, 7 had fever. Elevated CRP levels were detected before the onset of fever in two of the seven patients. Of the five remaining patients, the CRP levels on a previous test had been low; however, the fever developed suddenly. Of the 10 patients with no fever under weekly CRP monitoring, three had elevated CRP levels >3.0 mg/dL. Refraining from increasing the clozapine dose may have prevented fever in these patients. Among four patients with daily CRP measurements, two became febrile. In both cases, CRP levels increased almost simultaneously with the onset of fever. Conclusion Weekly and daily CRP monitoring during clozapine titration is valuable for preventing clozapine-induced inflammation, assessing its severity, and guiding clozapine dose adjustments. Weekly CRP monitoring may not adequately predict clozapine-induced inflammation in some cases. Consequently, clinicians should be aware of the sudden onset of clozapine-induced inflammation, even if CRP levels are low. Daily CRP monitoring is better for detecting clozapine-induced inflammation.
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Affiliation(s)
- Yuki Kikuchi
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Hiroaki Tanifuji
- Department of Pharmacy, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Sota Ueno
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Yoshifumi Onuma
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Masatomo Goto
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Masato Ishihara
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Takeshi Toraiwa
- Department of Psychiatry, Kodama Hospital, Ishinomaki, Miyagi, Japan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hiroaki Tomita
- Department of Psychiatry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
- Department of Psychiatry, Tohoku University Hospital, Sendai, Miyagi, Japan
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Leung JG, Zhang L, Markota M, Ellingrod VL, Gerberi DJ, Bishop JR. A systematic review of clozapine-associated inflammation and related monitoring. Pharmacotherapy 2023; 43:1364-1396. [PMID: 37842767 DOI: 10.1002/phar.2887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/17/2023]
Abstract
Clozapine is an effective antipsychotic medication used for treatment-resistant schizophrenia. However, it is underutilized due to rigorous hematologic monitoring requirements and many adverse drug reactions. Publications have highlighted the occurrence of inflammatory reactions, some life-threatening, particularly during the early stages of clozapine treatment. Although guidelines have suggested monitoring for inflammatory processes during clozapine initiation, screening in clinical practice is not universal. This systematic review aimed to investigate the relationship between clozapine and inflammation and assess the importance of monitoring for inflammatory reactions. A comprehensive literature search yielded 6915 unique publication records after removal of duplicates. After a rigorous screening process, 75 publications were included in the review, which focused on three main aspects: (i) the impact of clozapine on inflammatory markers, (ii) monitoring cardiac and other organ function during clozapine-associated inflammatory processes, and (iii) monitoring non-specific signs and symptoms of inflammation. Elevated levels of C-reactive protein (CRP) and several proinflammatory cytokines have been observed in association with clozapine treatment. However, the practicality of measuring specific markers in clinical practice remains uncertain. Current evidence supports monitoring CRP levels during the first 4-8 weeks of treatment, especially to facilitate myocarditis screening. Further research is needed to establish clinically relevant CRP thresholds for intervention. The implementation of monitoring protocols during the early phase of clozapine treatment may mitigate adverse reactions and allow for continued use of clozapine. Future studies should also explore the association between clozapine-associated inflammation and pneumonia, as well as investigate the impact of inflammation on clozapine metabolism to predict the need for dose adjustment. These endeavors may facilitate the development and implementation of evidence-based guidelines for the monitoring of clozapine-associated inflammation.
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Affiliation(s)
| | - Lusi Zhang
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Matej Markota
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vicki L Ellingrod
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Vaziri N, Marques D, Greenway SC, Bousman CA. The cellular mechanism of antipsychotic-induced myocarditis: A systematic review. Schizophr Res 2023; 261:206-215. [PMID: 37797362 DOI: 10.1016/j.schres.2023.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/23/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023]
Abstract
Antipsychotic drug-induced myocarditis is a serious and potentially fatal adverse drug reaction characterized by inflammation of the heart muscle (myocardium) that typically develops within the first month after commencing an antipsychotic drug. Although the precise mechanism of this severe adverse drug reaction is unknown, multiple theories have been proposed with varying levels of support from cellular or animal studies. We conducted a systematic review, in accordance with PRISMA guidelines, of published preclinical and clinical studies investigating the cellular mechanism by which antipsychotic drugs induce myocarditis. A literature search including all studies available before December 10, 2022, yielded 15 studies that met our inclusion criteria. Antipsychotics examined in the included studies included clozapine (n = 13), ziprasidone (n = 1), amisulpride (n = 1), haloperidol (n = 1), levomepromazine (n = 1), olanzapine (n = 1), and sertindole (n = 1). The evidence suggests several overlapping mechanistic cascades involving: (1) increased levels of catecholamines, (2) increased proinflammatory cytokines, (3) increased reactive oxygen species (ROS), (4) reduced antioxidant levels and activity, and (5) mitochondrial damage. Notable limitations such as, a focus on clozapine, sample heterogeneity, and use of supratherapeutic doses will need to be addressed in future studies. Discovery of the mechanism by which antipsychotic drugs induce myocarditis will allow the development of clinically-useful biomarkers to identify those patients at increased risk prior to drug exposure. The development or repurposing of therapeutics to prevent or treat drug-induced myocarditis will also be possible and this will enable increased and safe use of antipsychotics for those patients in need.
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Affiliation(s)
- Nazanin Vaziri
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Diogo Marques
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Steven C Greenway
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chad A Bousman
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, University of Calgary, Calgary, AB, Canada; Department of Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Clapham E, Reutfors J, Linder M, Brandt L, Sundström J, Bodén R. The association between exposure to clozapine, olanzapine, and quetiapine and the outcomes perimyocarditis and heart failure: A population-based cohort study. Psychiatry Res 2023; 326:115336. [PMID: 37451082 DOI: 10.1016/j.psychres.2023.115336] [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: 04/26/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
The risk of cardiac adverse events following clozapine use is debated and is unknown for the chemically related and widely used antipsychotics olanzapine and quetiapine. National Swedish registers were used to identify all patients 16-75 years old with antipsychotic dispensations between 2005 and 2018. The short-term outcome was a diagnosis of perimyocarditis (pericarditis and/or myocarditis) within two months of first dispensation, and the long-term outcome was heart failure (including cardiomyopathy) within three years. Cox regressions with time varying exposure were used to estimate hazard rates (HR) and their 95% confidence intervals (CI). A total of 201,045 individuals were included in the cohort. The risk of developing perimyocarditis during clozapine treatment tripled compared to no antipsychotic treatment (HR 3.4, CI 1.6-7.3), although the absolute rate remained comparably low. The long-term risk of heart failure during clozapine treatment was also elevated (HR 1.3, CI 1.1-1.7). Treatment with either or both olanzapine or quetiapine was not associated with an increased relative risk of perimyocarditis, or heart failure compared to no antipsychotic treatment. Clozapine use is therefore associated with a substantially elevated short-term risk of perimyocarditis and an increased risk of heart failure within three years.
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Affiliation(s)
- Eric Clapham
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden; Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden.
| | - Johan Reutfors
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Marie Linder
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden
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Thotamgari SR, Bath AS, Dhaliwal L, Kommineni SK, Aujla P, Brar V. Real world analysis of cardiac adverse events associated with clozapine: A pharmacovigilance analysis using food and drug administration adverse event reporting system. Gen Hosp Psychiatry 2022; 78:123-125. [PMID: 35396035 DOI: 10.1016/j.genhosppsych.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Sahith Reddy Thotamgari
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Anandbir S Bath
- Department of Cardiology, University of Tennessee, Memphis, TN, United States of America
| | - Lovekirat Dhaliwal
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Sai Karthik Kommineni
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, United States of America
| | - Perminder Aujla
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America
| | - Vijaywant Brar
- Department of Cardiology, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America.
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Catatonia and Schizophrenia in a Young Man with Autism Spectrum Disorder and Clozapine-Induced Myocarditis. Harv Rev Psychiatry 2022; 30:261-269. [PMID: 35849743 DOI: 10.1097/hrp.0000000000000334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Correll CU, Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Seppälä N, Howes OD. A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia. CNS Drugs 2022; 36:659-679. [PMID: 35759211 PMCID: PMC9243911 DOI: 10.1007/s40263-022-00932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.
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Affiliation(s)
- C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea de Bartolomeis
- Section on Clinical Psychiatry and Psychology, Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, University of Naples Federico II, Naples, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Niko Seppälä
- Department of Psychiatry Satasairaala, Harjavalta, Finland
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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de Leon J, Ruan CJ, Schoretsanitis G, Rohde C, Yağcıoğlu EA, Baptista T, Kirilochev OO, De las Cuevas C, Correll CU. An international guideline with six personalised titration schedules for preventing myocarditis and pneumonia associated with clozapine. Gen Psychiatr 2022; 35:e100773. [PMID: 35866000 PMCID: PMC9244675 DOI: 10.1136/gpsych-2022-100773] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022] Open
Abstract
White blood cell (WBC) monitoring has reduced clozapine-treated patient deaths associated with agranulocytosis to a rarity. However, clozapine protocols and package inserts worldwide provide no instructions for preventing myocarditis or pneumonia during clozapine titrations. Prescribers worldwide are largely unaware of that. Meanwhile, as they worry about agranulocytosis, their clozapine-treated patients are at risk of dying from pneumonia or myocarditis. Consequently, an international guideline with 104 authors from 50 countries/regions was recently published to provide personalised clozapine titration schedules for adult inpatients. This forum article reviews pneumonia and myocarditis occurring during clozapine titration, as well as the three most innovative aspects of this new guideline: (1) personalised titration, (2) C reactive protein (CRP) measures, and (3) dose predictions based on blood levels. Clozapine metabolism is influenced by 3 levels of complexity: (1) ancestry groups, (2) sex-smoking subgroups, and (3) presence/absence of poor metabolizer status. These 3 groups of variables should determine the maintenance dose and speed of clozapine titration; they are summarised in a table in the full-text. The international clozapine titration guideline recommends measuring CRP levels simultaneously with WBC, at baseline and weekly at least for the first 4 weeks of titration, the highest risk period for clozapine-induced myocarditis.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Hospital Santiago Apóstol, Vitoria-Gasteiz, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing An Ding Hospital, Beijing, China
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing An Ding Hospital, Beijing, China
| | - Georgios Schoretsanitis
- Psychiatry, University of Zürich, Zurich, Switzerland
- Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Christopher Rohde
- Affective Disorders, Aarhus University Hospital, Aarhus, Denmark
- Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Trino Baptista
- Physiology, Los Andes University Medical School, Merida, Bolivarian Republic of Venezuela
| | - Oleg O Kirilochev
- Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Astrahanskaâ, Russian Federation
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Christoph U Correll
- Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA
- Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
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de Leon J. The history of clozapine in clinical practice: From its introduction to a guideline proposing personalized titrations. J Psychopharmacol 2022; 36:657-660. [PMID: 35634693 DOI: 10.1177/02698811221101059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria-Gasteiz, Spain
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