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Griffiths K, Mellado MR, Chung R, Lally J, McQueen G, Sendt KV, Gillespie A, Ibrahim M, Richter A, Shields A, Ponsford M, Jolles S, Hodsoll J, Pollak TA, Upthegrove R, Egerton A, MacCabe JH. Changes in immunoglobulin levels during clozapine treatment in schizophrenia. Brain Behav Immun 2024; 115:223-228. [PMID: 37832895 DOI: 10.1016/j.bbi.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/20/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS Use of clozapine in treatment-resistant schizophrenia is often limited due to risk of adverse effects. Cross-sectional associations between clozapine treatment and low immunoglobulin levels have been reported, however prospective studies are required to establish temporal relationships. We tested the hypothesis that reductions in immunoglobulin levels would occur over the first 6 months following initiation of clozapine treatment. Relationships between immunoglobulin levels and symptom severity over the course of clozapine treatment were also explored. DESIGN This prospective observational study measured immunoglobulin (Ig) levels (A, M and G) in 56 patients with treatment-resistant schizophrenia at 6-, 12- and 24-weeks following initiation with clozapine. Clinical symptoms were also measured at 12 weeks using the positive and negative syndrome scale (PANSS). RESULTS IgA, IgG and IgM all decreased during clozapine treatment. For IgA and IgG the reduction was significant at 24 weeks (IgA: β = -32.66, 95% CI = -62.38, -2.93, p = 0.03; IgG: β = -63.96, 95% CI = -118.00, -9.31, p = 0.02). For IgM the reduction was significant at 12 and 24 weeks (12 weeks: β = -23.48, 95% CI = -39.56, -7.42, p = 0.004; 24 weeks: β = -33.12, 95 %CI = -50.30, -15.94, p = <0.001). Reductions in IgA and IgG during clozapine treatment were correlated with reductions in PANSS-total over 12 weeks (n = 32, IgA r = 0.59, p = 0.005; IgG r = 0.48, p = 0.03). CONCLUSIONS The observed reductions in immunoglobulin levels over six months of clozapine treatment add further evidence linking clozapine to secondary antibody deficiency. Associations between Ig reduction and symptom improvement may however indicate that immune mechanisms contribute to both desirable and undesirable effects of clozapine.
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Affiliation(s)
- Kira Griffiths
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Maria Ruiz Mellado
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Raymond Chung
- Department of Social Genetic and Developmental Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - John Lally
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK; Department of Psychiatry, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland; Department of Psychiatry, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Grant McQueen
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Kyra-Verena Sendt
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | | | - Muhammad Ibrahim
- Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Alex Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Adrian Shields
- Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Mark Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK; Henry Wellcome Building, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - John Hodsoll
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, UK; Early Intervention Service, Birmingham Womens and Childrens NHS Foundation Trust, UK
| | - Alice Egerton
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK.
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Osacka J, Kiss A, Pirnik Z. Possible involvement of apoptosis in the antipsychotics side effects: A minireview. Clin Exp Pharmacol Physiol 2022; 49:836-847. [PMID: 35575958 DOI: 10.1111/1440-1681.13671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 01/04/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022]
Abstract
Antipsychotics are used in the treatment of schizophrenia and other psychiatric disorders. Generally they are divided into typical and atypical ones, according to the fact that atypical antipychotics induce less side effects and are more effective in terms of social and cognitive improvements. Their pharmacological effects are mediated via broad range of receptors that consequently influence different cellular signaling pathways. Antipsychotics produce udesirable side effects that range from relatively minor to life-threatening ones. In vitro and in vivo studies have pointed to neurotoxic effect exerted by some antipsychotics and have shown that apoptosis might play role in some side effects induced by antipsyschotics, including tardive dyskinesia, weight gain, agranulocytosis, osteoporosis, myocarditis, etc. Although cumulative data have suggested safety of atypical antipsychotics use during pregnancy some of them have been shown to induce apoptotic neurodegenerative and structural changes in fetal brains with long-lasting impact on cognitive impairment of offsprings. Typical antipsychotics seem to be more cytotoxic than atypical ones. Recently, epidemiological studies have shown lower incidence of cancer in schizophrenic patients what suggest ability of antipsychotics to suppress risk of cancer development. Some antipsychotics have been reported to inhibit cancer cell proliferation and induce their apoptosis. Thus, antipsychotics apoptotic effect may be used as a tool in the treatmnet of some types of cancer, especially in combinatorial therapies. In this minireview, we focused on pro- and anti-apototic or "Dr. Jekyll and Mr. Hyde" effects of antipsychotics, which can be involved in their side effects, as well as their promising therapeutical indications. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jana Osacka
- Biomedical Research Center, Slovak Academy of Sciences, Institute of Experimental Endocrinology, Dubravska cesta 9, Bratislava, Slovakia
| | - Alexander Kiss
- Biomedical Research Center, Slovak Academy of Sciences, Institute of Experimental Endocrinology, Dubravska cesta 9, Bratislava, Slovakia
| | - Zdenko Pirnik
- Biomedical Research Center, Slovak Academy of Sciences, Institute of Experimental Endocrinology, Dubravska cesta 9, Bratislava, Slovakia.,Institute of Physiology, Faculty of Medicine Comenius University in Bratislava, Sasinkova 2, Bratislava, Slovakia.,Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences, Flemingovo nam., 2Prague, Czech Republic
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3
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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Jaswal S, Sidana A, Mehta S, Gupta S, Kaur G. Comparative effects of clozapine and risperidone monotherapy on levels of immunoglobulins in patients with schizophrenia – A 12 weeks' longitudinal study. JOURNAL OF MENTAL HEALTH AND HUMAN BEHAVIOUR 2022. [DOI: 10.4103/jmhhb.jmhhb_24_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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5
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Seifert J, Heck J, Eckermann G, Singer M, Bleich S, Grohmann R, Toto S. [Vaccination Against COVID-19 in Patients Treated with Psychotropic Drugs]. PSYCHIATRISCHE PRAXIS 2021; 48:399-403. [PMID: 34344044 PMCID: PMC8570910 DOI: 10.1055/a-1531-4460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Vaccines against SARS-CoV-2 have been available in the European Union since December 2020. Persons suffering from mental illness have an increased risk of a severe or fatal course following an infection with SARS-CoV-2. Thus, the question arises to what extent interactions between the newly approved vaccines and psychotropic drugs may be expected. Data on the tolerability and efficacy of vaccines against SARS-CoV-2 under treatment with psychotropic drugs are not available to date - however, potential interactions can be derived from previous investigations on vaccines against other pathogens, such as a reduced immune response with lower clinical efficacy and an increase in drug plasma levels due to the indirect vaccine-mediated inhibition of metabolizing enzymes. On the other hand, depressed patients treated with antidepressant medication show a better immune response.
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Affiliation(s)
- Johanna Seifert
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
| | - Johannes Heck
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover
| | - Gabriel Eckermann
- Klinik für Forensische Psychiatrie und Psychotherapie, Bezirkskrankenhaus Kaufbeuren, Kaufbeuren
| | - Monika Singer
- kbo-Lech-Mangfall-Klinik Agatharied, Fachklinik für Psychiatrie, Psychotherapie und Psychosomatik, Hausham
| | - Stefan Bleich
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
| | - Renate Grohmann
- Klinik für Psychiatrie und Psychotherapie, Ludwig-Maximilians-Universität München, München
| | - Sermin Toto
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
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Peter HH, Ochs HD, Cunningham-Rundles C, Vinh DC, Kiessling P, Greve B, Jolles S. Targeting FcRn for immunomodulation: Benefits, risks, and practical considerations. J Allergy Clin Immunol 2020; 146:479-491.e5. [PMID: 32896308 PMCID: PMC7471860 DOI: 10.1016/j.jaci.2020.07.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The neonatal fragment crystallizable (Fc) receptor (FcRn) functions as a recycling mechanism to prevent degradation and extend the half-life of IgG and albumin in the circulation. Several FcRn inhibitors selectively targeting IgG recycling are now moving rapidly toward clinical practice in neurology and hematology. These molecules accelerate the destruction of IgG, reducing pathogenic IgG and IgG immune complexes, with no anticipated effects on IgA, IgM, IgE, complement, plasma cells, B cells, or other cells of the innate or adaptive immune systems. FcRn inhibitors have potential for future use in a much wider variety of antibody-mediated autoimmune diseases. Given the imminent clinical use, potential for broader utility, and novel mechanism of action of FcRn inhibitors, here we review data from 4 main sources: (a) currently available activity, safety, and mechanism-of-action data from clinical trials of FcRn inhibitors; (b) other procedures and treatments that also remove IgG (plasma donation, plasma exchange, immunoadsorption); (c) diseases resulting in loss of IgG; and (d) primary immunodeficiencies with potential mechanistic similarities to those induced by FcRn inhibitors. These data have been evaluated to provide practical considerations for the assessment, monitoring, and reduction of any potential infection risk associated with FcRn inhibition, in addition to highlighting areas for future research.
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Affiliation(s)
- Hans-Hartmut Peter
- Freiburg University Hospital, Centre for Chronic Immunodeficiency, Freiburg, Germany
| | - Hans D Ochs
- Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics, University of Washington, Seattle, Wash
| | | | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine and Department of Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada; Infectious Diseases & Immunity in Global Health Program, Research Institute-McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom.
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Kaplan B, Bonagura VR. Secondary Hypogammaglobulinemia: An Increasingly Recognized Complication of Treatment with Immunomodulators and After Solid Organ Transplantation. Immunol Allergy Clin North Am 2019; 39:31-47. [PMID: 30466771 DOI: 10.1016/j.iac.2018.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Secondary hypogammaglobulinemia is a common development in patients treated with immunomodulatory agents for autoimmune, connective tissue, and malignant diseases. It has been observed in the medical management of patients undergoing hematopoietic stem cell and solid organ transplantation. Some patients have preexisting immunodeficiency associated with these illnesses; immunosuppressive treatment magnifies their immune defect. This article reviews immunosuppressive medications, including biological treatments that cause secondary hypogammaglobulinemia. It summarizes risk factors for rituximab-induced hypogammaglobulinemia, such as preexisting low immunoglobulin G levels, CD19 levels, host factors, and additive effect of all immunomodulatory drugs used. The evaluation and management of secondary hypogammaglobulinemia are discussed.
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Affiliation(s)
- Blanka Kaplan
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA.
| | - Vincent R Bonagura
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA
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Jolles S, Chapel H, Litzman J. When to initiate immunoglobulin replacement therapy (IGRT) in antibody deficiency: a practical approach. Clin Exp Immunol 2017; 188:333-341. [PMID: 28000208 DOI: 10.1111/cei.12915] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
Primary antibody deficiencies (PAD) constitute the majority of all primary immunodeficiency diseases (PID) and immunoglobulin replacement forms the mainstay of therapy for many patients in this category. Secondary antibody deficiencies (SAD) represent a larger and expanding number of patients resulting from the use of a wide range of immunosuppressive therapies, in particular those targeting B cells, and may also result from renal or gastrointestinal immunoglobulin losses. While there are clear similarities between primary and secondary antibody deficiencies, there are also significant differences. This review describes a practical approach to the clinical, laboratory and radiological assessment of patients with antibody deficiency, focusing on the factors that determine whether or not immunoglobulin replacement should be used. The decision to treat is more straightforward when defined diagnostic criteria for some of the major PADs, such as common variable immunodeficiency disorders (CVID) or X-linked agammaglobulinaemia (XLA), are fulfilled or, indeed, when there is a very low level of immunoglobulin production in association with an increased frequency of severe or recurrent infections in SAD. However, the presentation of many patients is less clear-cut and represents a considerable challenge in terms of the decision whether or not to treat and the best way in which to assess the outcome of therapy. This decision is important, not least to improve individual quality of life and reduce the morbidity and mortality associated with recurrent infections but also to avoid inappropriate exposure to blood products and to ensure that immunoglobulin, a costly and limited resource, is used to maximal benefit.
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Affiliation(s)
- S Jolles
- Immunodeficiency Centre for Wales, Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - H Chapel
- Department of Clinical Immunology, University of Oxford, UK
| | - J Litzman
- Department of Clinical Immunology and Allergology, St Annes's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Bergemann N. Hormontherapie und schizophrene Psychosen. GYNAKOLOGISCHE ENDOKRINOLOGIE 2011. [DOI: 10.1007/s10304-010-0387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Furst DE. Serum immunoglobulins and risk of infection: how low can you go? Semin Arthritis Rheum 2008; 39:18-29. [PMID: 18620738 DOI: 10.1016/j.semarthrit.2008.05.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 05/02/2008] [Accepted: 05/04/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the relationship between the levels of serum immunoglobulin (Ig) levels and risk of infection. The following 2 main questions are addressed: (1) At what level do reduced serum concentrations of the different Ig species (focusing on IgA, IgG, and IgM) significantly increase the risk of infection above background and (2) For how long can Ig depletion be tolerated before an increased risk of infection becomes apparent. METHODS Information was gathered from a search of PubMed and relevant congress abstracts up to and including November 2007. RESULTS Sustained, very low levels of IgA, IgG, or IgM, as occur in primary immunodeficiency syndromes, are associated with significantly increased risks of infections, primarily respiratory tract infections of bacterial origin. Patients with IgG levels <100 mg/dL or IgM levels <20 mg/dL for prolonged periods have an increased risk of recurrent and sometimes life-threatening infectious episodes. Generally, IgA deficiency appears better tolerated. Replenishment of IgG in patients with hypogammaglobulinemia reduces the infection risk to background if IgG levels are maintained at approximately 500 mg/dL, although higher levels may be necessary in the presence of certain comorbidities. Transient depletion of IgG and/or IgM (or, less commonly, IgA) can occur in some patients following the administration of certain drugs, including anticonvulsants, corticosteroids, and rituximab. Available evidence suggests that such changes are not generally associated with an increased risk of infections. CONCLUSIONS While prolonged, very low levels of IgG and/or IgM are associated with a heightened risk of infections, transient or less severe immunodeficiency appears to be tolerated in most subjects.
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Affiliation(s)
- Daniel E Furst
- University of California, Los Angeles, CA 90095-1670, USA.
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