Diarrhoea during treatment with clozapine: association with lymphocyte count

Drug-Induced Colitis

Drug-induced colitis encompasses a wide spectrum of colon disorders that can manifest microscopically or macroscopically. Patients present with new-onset colitis or exacerbations of inflammatory bowel diseases; in some cases, colitis resolves with discontinuation of medication. Mucosal injury can be focal or extensive, involving the entire colonic mucosa, and sometimes involves other parts of the gastrointestinal tract. It has been a challenge to determine the proportion of new-onset colitis caused by medication and there are few data on the overall prevalence. We review the drugs that have been linked with development of drug-induced colitis and strategies for physicians who believe their patients have this disorder-usually discontinuation of the drug believed to cause colitis and treatment with steroids or immune-modulating therapies. Physicians must be aware of medications that can cause colitis.

Clozapine-Related Diarrhea and Colitis: Report of 4 Cases

BACKGROUND

During clozapine treatment, diarrhea is a rare but clinically relevant adverse effect. Cases of microscopic colitis and eosinophilic colitis have been previously reported.

PROCEDURES

We present 4 patients who developed severe diarrhea in early weeks of clozapine therapy.

FINDINGS

Two patients had significant peripheral eosinophilia 1 week after diarrhea symptoms. One of these patients also had Charcot-Leyden crystals in stool afterward, confirming the presence of eosinophils in the gut lumen. One of our patients had a confirmed microscopic colitis and later also neutropenia, which required treatment.

CONCLUSIONS

Charcot-Leyden crystals in stool may be associated with concurrent diarrhea and eosinophilia during clozapine treatment, which is a previously unreported finding. Occurrence of blood dyscrasias with diarrhea symptoms during clozapine treatment needs further investigation to understand the possible shared mechanisms.

Clozapine induced gastrointestinal hypomotility: A potentially life threatening adverse event. A review of the literature

OBJECTIVE

The haematological and cardiac complications of clozapine have been well documented. Recent evidence from pharmacovigilance databases suggests that gastrointestinal (GI) complications are the leading cause of clozapine related deaths. This review aims to describe clinical features along with preventative and treatment options.

METHOD

A review of MEDLINE via PubMed searching for all articles published up to February of 2016. Inclusion criteria were articles that provided clinical or epidemiological information relating to the diagnosis, outcome, management or pathophysiology of clozapine related gastrointestinal disorders in humans.

RESULTS

Three large case series were identified with 104 cases, 20 of these reported clinical details. A further 52 cases reports were included. Median age was 40, with 79% being male, mean daily clozapine dose was 453 mg. Mortality was 38% with survivors being younger (39 vs. 42), on lower daily doses (400 mg vs. 532 mg), more likely to be female (32% vs. 6%). Four patients were re-challenged with clozapine following CIGH, two suffered a recurrence.

CONCLUSION

Risk factors for CIGH appear to be older age, male gender, patients in the first four months of treatment, co-prescription of constipating agents, higher daily dose of clozapine, and previous CIGH. Risk factors for death were older age and male gender. Patients receiving clozapine should be counselled about the dangers of constipation and to report new GI symptoms. Once severe CIGH has occurred clozapine should be halted and reviewed with bowel symptoms managed promptly. Re-challenging with clozapine may present substantial risks due to the severity of CIGH and a paucity of evidence. From the available evidence a treatment strategy has been proposed. Further prospective data regarding CIGH are needed to allow a better assessment of the scale of the problem with the development and testing of treatment strategies.

Clozapine-induced microscopic colitis: a case report and review of the literature

Both diarrhea and colitis associated with clozapine have been reported. In this article, the authors present a case of clozapine-induced microscopic colitis (MC)-the first reported in the literature. The definitive diagnosis was suggested on colon biopsy, which showed an intraepithelial lymphocytosis (with >20 lymphocytes for every 100 epithelial cells) more striking in the surface epithelium than in the crypts. In addition, there were a mixed inflammatory infiltrate in the lamina propria (with lymphocytes predominating over eosinophils and neutrophils), an architecturally preserved colonic mucosa (particularly in the crypts), and a subepithelial collagen band normally thickened (<10 microm). Clozapine was thought to be the culprit and discontinued. After some days, the patient gradually improved. Diarrhea and spiking fever disappeared within 72 hours. Multiple colon biopsies taken after 7 days from the discontinuation of the clozapine revealed no abnormal histological findings. It is important to clarify the issue of clozapine-induced MC because MC may require the use of expensive or potentially toxic treatments and can occasionally be life-threatening (eg, hypokalemia). Thus, any case of MC that can be cured by withdrawal of the clozapine must be investigated and identified.