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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity induced by clozapine: Case report and brief review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2023; 52:165-170. [PMID: 37460343 DOI: 10.1016/j.rcpeng.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/21/2021] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru
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2
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Grant RK, Brindle WM, Donnelly MC, McConville PM, Stroud TG, Bandieri L, Plevris JN. Gastrointestinal and liver disease in patients with schizophrenia: A narrative review. World J Gastroenterol 2022; 28:5515-5529. [PMID: 36304087 PMCID: PMC9594005 DOI: 10.3748/wjg.v28.i38.5515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 02/06/2023] Open
Abstract
Schizophrenia is a severe mental illness which can have a devastating impact on an individual's quality of life. Comorbidities are high amongst patients and life expectancy is approximately 15 years less than the general population. Despite the well-known increased mortality, little is known about the impact of gastrointestinal and liver disease on patients with schizophrenia. We aimed to review the literature and to make recommendations regarding future care. Literature searches were performed on PubMed to identify studies related to gastrointestinal and liver disease in patients with schizophrenia. High rates of chronic liver disease were reported, with Non-Alcoholic Fatty Liver Disease being of particular concern; antipsychotics and metabolic syndrome were contributing factors. Rates of acute liver failure were low but have been associated with antipsychotic use and paracetamol overdose. Coeliac disease has historically been linked to schizophrenia; however, recent research suggests that a causal link is yet to be proven. Evidence is emerging regarding the relationships between schizophrenia and peptic ulcer disease, inflammatory bowel disease and irritable bowel syndrome; clinical vigilance regarding these conditions should be high. Patients with schizophrenia poorly engage with bowel cancer screening programmes, leading to late diagnosis and increased mortality. Clozapine induced constipation is a significant issue for many patients and requires close monitoring. There is a significant burden of gastrointestinal and liver disease amongst patients with schizophrenia. Better levels of support from all members of the medical team are essential to ensure that appropriate, timely care is provided.
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Affiliation(s)
- Rebecca K Grant
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - William M Brindle
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Mhairi C Donnelly
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Pauline M McConville
- General Adult Psychiatry, Royal Edinburgh Hospital, Edinburgh, EH10 5HF, United Kingdom
| | - Thomas G Stroud
- General Adult Psychiatry, Royal Edinburgh Hospital, Edinburgh, EH10 5HF, United Kingdom
| | - Lorenzo Bandieri
- General Adult Psychiatry, Royal Edinburgh Hospital, Edinburgh, EH10 5HF, United Kingdom
| | - John N Plevris
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity Induced by Clozapine: Case Report and Brief Review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 52:S0034-7450(21)00087-1. [PMID: 34167791 DOI: 10.1016/j.rcp.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/22/2020] [Accepted: 04/21/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú
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Druschky K, Toto S, Bleich S, Baumgärtner J, Engel RR, Grohmann R, Maier HB, Neyazi A, Rudolph YJ, Rüther E, Schwörer H, Seifert J, Stübner S, Degner D. Severe drug-induced liver injury in patients under treatment with antipsychotic drugs: Data from the AMSP study. World J Biol Psychiatry 2021; 22:373-386. [PMID: 32892689 DOI: 10.1080/15622975.2020.1819565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Drug-induced liver injury (DILI) has been associated with various antipsychotic drugs (APDs). Comparative studies between individual APDs are largely not available. METHODS Antipsychotic drug utilisation data and reports of severe antipsychotic DILI were assessed by using data from an observational pharmacovigilance programme-Arzneimittelsicherheit in der Psychiatrie (AMSP)-during the period 1993-2016. RESULTS Of the 333,175 patients treated with APDs, a total of 246 (0.07%) events of severe DILI were identified. Phenothiazines were associated with significantly higher rates of severe DILI (0.03%, 95% CI = 0.02-0.04) than thioxanthenes (0.01%, 95% CI = 0.00-0.02) or butyrophenones (0.01%, 95% CI = 0.00-0.01). Among individual drugs, olanzapine (0.12%, 95% CI = 0.10-0.16), perazine (0.09%, 95% CI = 0.05-0.15) and clozapine (0.09%, 95% CI = 0.10-0.12 ranked highest. In 78 cases (31.7%), combination therapies with antipsychotic and antidepressant drugs or with two or more APDs were considered responsible. Male sex and a diagnosis of mania were associated with significantly higher rates of severe DILI while older patients (≥65 years old) were significantly less often affected. CONCLUSIONS In the present analysis of a representative psychiatric inpatient cohort, olanzapine, perazine, and clozapine were the most common individual APDs associated with severe DILI.
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Affiliation(s)
- Katrin Druschky
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Augsburg, Germany
| | - Rolf R Engel
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Yannick J Rudolph
- Department of Psychiatry and Psychotherapy, Georg-August University of Goettingen, Goettingen, Germany
| | - Eckart Rüther
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Harald Schwörer
- Department of Gastroenterology and Gastrointestinal Oncology, Liver Center Goettingen, University Medical Center Goettingen, Georg-August University of Goettingen, Göttingen, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Susanne Stübner
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Munich, Germany.,Department of Forensic Psychiatry, Kbo-IAK, Academic Teaching Hospital of the Ludwig-Maximilian University, Munich, Germany
| | - Detlef Degner
- Department of Psychiatry and Psychotherapy, Georg-August University of Goettingen, Goettingen, Germany
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Todorović Vukotić N, Đorđević J, Pejić S, Đorđević N, Pajović SB. Antidepressants- and antipsychotics-induced hepatotoxicity. Arch Toxicol 2021; 95:767-789. [PMID: 33398419 PMCID: PMC7781826 DOI: 10.1007/s00204-020-02963-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/26/2020] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.
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Affiliation(s)
- Nevena Todorović Vukotić
- Department of Molecular Biology and Endocrinology, "Vinča" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 12-14 Mike Petrovića Alasa, P.O. Box 522-090, 11000, Belgrade, Serbia.
| | - Jelena Đorđević
- Institute of Physiology and Biochemistry "Ivan Đaja", Faculty of Biology, University of Belgrade, 16 Studentski Trg, 11000, Belgrade, Serbia
| | - Snežana Pejić
- Department of Molecular Biology and Endocrinology, "Vinča" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 12-14 Mike Petrovića Alasa, P.O. Box 522-090, 11000, Belgrade, Serbia
| | - Neda Đorđević
- Department of Molecular Biology and Endocrinology, "Vinča" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 12-14 Mike Petrovića Alasa, P.O. Box 522-090, 11000, Belgrade, Serbia
| | - Snežana B Pajović
- Department of Molecular Biology and Endocrinology, "Vinča" Institute of Nuclear Sciences, National Institute of the Republic of Serbia, University of Belgrade, 12-14 Mike Petrovića Alasa, P.O. Box 522-090, 11000, Belgrade, Serbia.,Faculty of Medicine, University of Niš, 81 Blvd. Dr. Zorana Đinđića, 18000, Niš, Serbia
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Prieto de Paula JM, Martín-Luquero Ibáñez M, Martín Guerra J, Cepedello Pérez S, Franco Hidalgo S, Prieto Dehesa M, Martín Asenjo M. Clozapina and acute hepatitis. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2020; 13:49-50. [PMID: 30971381 DOI: 10.1016/j.rpsm.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/17/2018] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Affiliation(s)
| | | | - Javier Martín Guerra
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Sandra Cepedello Pérez
- Servicio de Psiquiatría, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Silvia Franco Hidalgo
- Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - Mario Prieto Dehesa
- Medicina Familiar y Comunitaria, Centro de Salud Covaresa, Valladolid Oeste, Valladolid, España
| | - Miguel Martín Asenjo
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, España
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7
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Takács A, Sollychin M, Thomas N, Connally F, Pantelis C. Clozapine rechallenge in a patient with clozapine-induced hepatitis. Australas Psychiatry 2019; 27:535. [PMID: 31545088 DOI: 10.1177/1039856219848824] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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8
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Vorrink SU, Zhou Y, Ingelman-Sundberg M, Lauschke VM. Prediction of Drug-Induced Hepatotoxicity Using Long-Term Stable Primary Hepatic 3D Spheroid Cultures in Chemically Defined Conditions. Toxicol Sci 2019; 163:655-665. [PMID: 29590495 PMCID: PMC5974779 DOI: 10.1093/toxsci/kfy058] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
High failure rates of drug candidates in the clinics, restricted-use warnings as well as withdrawals of drugs in postmarketing stages are of substantial concern for the pharmaceutical industry and drug-induced liver injury (DILI) constitutes one of the most frequent reasons for such safety failures. Importantly, as DILI cannot be accurately predicted using animal models, animal safety tests are commonly complemented with assessments in human in vitro systems. 3D spheroid cultures of primary human hepatocytes in chemically defined conditions, hereafter termed CD-spheroids, have recently emerged as a microphysiological model system in which hepatocytes retain their molecular phenotypes and hepatic functions for multiple weeks in culture. However, their predictive power for the detection of hepatotoxic liabilities has not been systematically assessed. Therefore, we here evaluated the hepatotoxicity of 123 drugs with or without direct implication in clinical DILI events. Importantly, using ATP quantifications as the single endpoint, the model accurately distinguished between hepatotoxic and nontoxic structural analogues and exceeded both sensitivity and specificity of all previously published in vitro assays at substantially lower exposure levels, successfully detecting 69% of all hepatotoxic compounds without producing any false positive results (100% specificity). Furthermore, the platform supports the culture of spheroids of primary hepatocytes from preclinical animal models, thereby allowing the identification of animal-specific toxicity events. We anticipate that CD-spheroids represent a powerful and versatile tool in drug discovery and preclinical drug development that can reliably flag hepatotoxic drug candidates and provide guidance for the selection of the most suitable animal models.
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Affiliation(s)
- Sabine U Vorrink
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden
| | - Yitian Zhou
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden
| | - Magnus Ingelman-Sundberg
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden
| | - Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden
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9
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Hepatitis, Interstitial Nephritis, and Pancreatitis in Association With Clozapine Treatment: A Systematic Review of Case Series and Reports. J Clin Psychopharmacol 2018; 38:520-527. [PMID: 30059436 DOI: 10.1097/jcp.0000000000000922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/BACKGROUND Clozapine is the criterion standard in treatment-resistant schizophrenia. We sought to review data on several inflammatory effects associated with clozapine, specifically interstitial nephritis, hepatitis, and pancreatitis. METHODS/PROCEDURES We conducted a systematic review to identify studies, published up until December 2017, describing clozapine-induced hepatitis, nephritis, and pancreatitis. The primary objective was to characterize the clinical characteristics associated with each of the specific inflammatory reactions to clozapine. FINDINGS/RESULTS We identified 42 cases of inflammatory reactions associated with clozapine treatment- 20 :cases of clozapine-induced hepatitis, 11 cases of nephritis, and 11 of pancreatitis. The mean (SD) age was 38.8 (11.9) years. The mean (SD) dose of clozapine used was 252.4 (133.7) mg. Time to onset of pancreatitis (17.9 [11.2] days; range 4-35 days) was shorter than that for hepatitis (34.2 [20.1] days; range, 12-90 days) and nephritis (27.9 [27.0]; range, 8-90 days) but was not statistically significant (F = 2.267, P = 0.117). The mean (SD) time to recovery was shorter for cases of pancreatitis (15.7 [18.4] days) compared with cases of hepatitis (25.9 [16.5] days) and nephritis (24.5 [18.9] days). Three cases with hepatitis died. Seven of the cases had a clozapine rechallenge (hepatitis [n = 3], nephritis [n = 1], pancreatitis [n = 3]), with 5 having a recurrence at a mean (SD) onset of 3.5 (2.5) days (range, 1-7 days); 2 hepatitis cases were successfully rechallenged. IMPLICATIONS/CONCLUSIONS Clozapine-induced hepatitis, nephritis, and pancreatitis are uncommon adverse events, reflected in the paucity of case studies in the literature. Early recognition of the signs and symptoms of clozapine-associated hepatitis, nephritis, and pancreatitis is important, as when identified, clozapine should be urgently discontinued. Clozapine is associated with evidence of benign inflammatory processes; the extent to which hepatitis, and other inflammatory reactions, may be on a continuum with these more benign and self-limiting reactions is unclear, and this can only be resolved by prospectively following cohorts of clozapine-treated patients.
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Abstract
The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.
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11
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Ng W, Kennar R, Uetrecht J. Effect of Clozapine and Olanzapine on Neutrophil Kinetics: Implications for Drug-Induced Agranulocytosis. Chem Res Toxicol 2014; 27:1104-8. [DOI: 10.1021/tx500183x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Winnie Ng
- Department of Pharmaceutical Sciences, Leslie Dan Faculty
of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2
| | - Rossoune Kennar
- Département Génie Biologique, Polytech’ Nice-Sophia, Site des Templiers, 930 Route des Colles, 06903 Sophia-Antipolis Cedex, France
| | - Jack Uetrecht
- Department of Pharmaceutical Sciences, Leslie Dan Faculty
of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2
- Department of Pharmacology and Toxicology,
Faculty of Medicine, University of Toronto, 27 King’s College Circle, Toronto, Ontario Canada M5S 1A8
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12
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Wu Chou AI, Lu ML, Shen WW. Hepatotoxicity induced by clozapine: a case report and review of literature. Neuropsychiatr Dis Treat 2014; 10:1585-7. [PMID: 25210451 PMCID: PMC4155895 DOI: 10.2147/ndt.s67654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Clozapine is an effective antipsychotic drug but is associated with serious side effects. Most treatment guidelines give no clear recommendations on regular monitoring of liver function tests, even though up to 60% of patients experience elevations in hepatic transaminases, with 15% to 30% experiencing an elevation two to three times greater than normal. Though elevations in liver function tests are often transient and asymptomatic, there are many reported cases of clozapine-induced hepatotoxicity, with damage to the liver, involvement of multiple organs, and even fulminant liver failure arising with moderate clozapine doses. This case report describes a Chinese woman who developed hepatotoxicity on a low dose of clozapine, and reviews the relevant literature.
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Affiliation(s)
- Ana Isabel Wu Chou
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan ; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Winston W Shen
- Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan ; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
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13
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Affiliation(s)
- Peter Tucker
- Concord Centre for Mental Health, Concord, Australia
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14
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Kang SH, Lee JI. Eosinophilia, pleural effusion, hepatitis, and jaundice occurring early in clozapine treatment. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2013; 11:103-5. [PMID: 24023555 PMCID: PMC3766753 DOI: 10.9758/cpn.2013.11.2.103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/25/2013] [Indexed: 12/23/2022]
Abstract
Clozapine use is associated with various adverse events, some of which have received little attention, including eosinophilia, pleural effusion, and hepatitis. Because of the fatality of jaundice with hepatitis, it is necessary to understand the course and management of clozapine-induced eosinophilia and hepatitis. We report on a case in which the eosinophil count began to increase shortly after clozapine use, and pleural effusion and fever then developed at the time eosinophilia was at its peak level. Jaundice with hepatitis consecutively developed when all the above symptoms subsided. The liver function recovered rapidly after clozapine was discontinued. We recommend that patients who develop rapid eosinophilia at the beginning of clozapine treatment should be monitored with LFTs, chest X-rays, and urine analysis tests.
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Affiliation(s)
- Shi Hyun Kang
- Department of Psychiatry, Seoul National Hospital, Seoul, Korea
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15
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Manu P, Sarpal D, Muir O, Kane JM, Correll CU. When can patients with potentially life-threatening adverse effects be rechallenged with clozapine? A systematic review of the published literature. Schizophr Res 2012; 134:180-6. [PMID: 22113154 PMCID: PMC3318984 DOI: 10.1016/j.schres.2011.10.014] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 10/20/2011] [Accepted: 10/24/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine is widely prescribed for treatment refractory patients with schizophrenia, but its use is limited by potentially life threatening adverse effects. Rechallenge after these complications has been occasionally attempted in patients with severe psychotic symptoms. OBJECTIVE To review the outcome of clozapine rechallenge after potentially life threatening adverse effects. METHODS Electronic, all-language, literature search (1972-2011) followed by demographic and clinical data extraction. The outcome of rechallenge was considered favorable when the lower bound of the 95% confidence interval (CI) of the proportion of patients who could continue clozapine was >50%. RESULTS Altogether, 138 patients (mean age: 36.3years, 65.7% male, 57.6% Caucasian, virtually all with schizophrenia spectrum diagnosis) underwent clozapine rechallenge after developing neutropenia (n=112), agranulocytosis (n=15), neuroleptic malignant syndrome (NMS) (n=5), myocarditis (n=4), pericarditis (n=1) and lupus erythematosus (n=1). Rechallenge strategies were heterogeneous and not systematically evaluated. Clozapine rechallenge was successful in 78/112 patients (69.6%, CI: 60.6-77.4) after neutropenia, 3/15 (20%, CI: 7.1-45.2) after agranulocytosis, 5/5 (100%, CI: 56-100) after NMS, 3/4 (75%, CI: 30-95) after myocarditis, 1/1 after pericarditis, and 0/1 after clozapine-induced lupus. Successfully rechallenged patients were followed for 16-96weeks. None of the rechallenged patients died. CONCLUSIONS Although controlled studies are clearly needed, using a priori, confidence interval-based criteria, case reports/series suggest that in refractory patients who benefited from clozapine, careful rechallenge can be considered after neutropenia and NMS, but not after agranulocytosis and myocarditis.
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Affiliation(s)
- Peter Manu
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Deepak Sarpal
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - Owen Muir
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - John M. Kane
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
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Re: Recent case report of clozapine-induced acute hepatic failure. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 24:739-40; author reply 741. [PMID: 21165382 DOI: 10.1155/2010/535026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Gómez Espín R, Sánchez Quiles I, Hallal H, Plaza J. [Acute hepatocellular lesion after successive exposure to clozapine and olanzapine in a patient with chronic hepatitis C infection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:150-152. [PMID: 19914745 DOI: 10.1016/j.gastrohep.2009.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 08/06/2009] [Accepted: 08/10/2009] [Indexed: 05/28/2023]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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