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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 DOI: 10.1007/s40263-024-01100-4] [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: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Yang R, Wan JL, Pi CQ, Wang TH, Zhu XQ, Zhou SJ. Increased antipsychotic drug concentration in hospitalized patients with mental disorders following COVID-19 infection: a call for attention. Front Psychiatry 2024; 15:1421370. [PMID: 39077630 PMCID: PMC11284031 DOI: 10.3389/fpsyt.2024.1421370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024] Open
Abstract
Purpose Examine the alterations in antipsychotic concentrations following coronavirus disease-2019 (COVID-19) infection among hospitalized patients with mental disorders and conduct an analysis of the factors influencing these changes. Methods Data were collected from inpatients at Beijing Huilongguan Hospital between December 12, 2022, and January 11, 2023, pre- and post-COVID-19. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 329 inpatients with mental disorders were included (3 with incomplete data excluded). Primary outcomes assessed changes in antipsychotic concentrations pre- and post-COVID-19, while secondary outcomes examined factors linked to concentration increases and antipsychotic dose adjustments. Results Clozapine (P < 0.001), aripiprazole (P < 0.001), quetiapine (P = 0.005), olanzapine (P < 0.001), risperidone (P < 0.001), and paliperidone (P < 0.001) concentrations increased post-COVID-19 in patients with mental disorders. Notably, clozapine concentration surpassing pre-infection levels was highest. Clozapine users were more likely to adjust their dose (50.4%) compared to olanzapine (17.5%) and other antipsychotics. Moreover, traditional Chinese patent medicines and antibiotics during COVID-19 infection were associated with antipsychotic reduction or withdrawal (OR = 2.06, P = 0.0247; OR = 7.53, P = 0.0024, respectively). Conclusion Antipsychotic concentrations in hospitalized patients with mental disorders increased after COVID-19 infection, that may be related not only to COVID-19, but also to the use of Chinese patent medicines during infection. The pre-infection concentration and types of antipsychotics, patient's gender, and combination of traditional Chinese medicine or antibiotics, were factors found to correlate with increased drug concentrations and necessitate dose adjustments.
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Affiliation(s)
- Rui Yang
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jin-Ling Wan
- Zhangjiakou Shalingzi Hospital, Zhangjiakou Mental Health Center, Zhangjiakou, Hebei, China
| | - Chen-Qi Pi
- Psychiatry Department, Shunyi Women’s & Children’s Hospital of Beijing Children’s Hospital, Beijing, China
| | - Tian-Hui Wang
- Psychiatry Department, Shunyi Women’s & Children’s Hospital of Beijing Children’s Hospital, Beijing, China
| | - Xue-Quan Zhu
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Shuang-Jiang Zhou
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China
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3
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Hart XM, Gründer G, Ansermot N, Conca A, Corruble E, Crettol S, Cumming P, Hefner G, Frajerman A, Howes O, Jukic M, Kim E, Kim S, Manisalco I, Moriguchi S, Müller DJ, Nakajima S, Osugo M, Paulzen M, Ruhe HG, Scherf-Clavel M, Schoretsanitis G, Serretti A, Spina E, Spigset O, Steimer W, Süzen HS, Uchida H, Unterecker S, Vandenberghe F, Verstuyft C, Zernig G, Hiemke C, Eap CB. Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: focus on antipsychotics. World J Biol Psychiatry 2024:1-123. [PMID: 38913780 DOI: 10.1080/15622975.2024.2366235] [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] [Received: 11/04/2023] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialized tools are used. Three tools have been proven useful to personalize drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging. METHODS In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 50 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)). RESULTS Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings. CONCLUSION All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimize treatment effects, minimize side effects and ultimately reduce the global burden of diseases, personalized drug treatment has not yet become the standard of care in psychiatry.
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Affiliation(s)
- X M Hart
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - G Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- German Center for Mental Health (DZPG), partner site Mannheim - Heidelberg - Ulm
| | - N Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - A Conca
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - E Corruble
- Université Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - S Crettol
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - P Cumming
- Department of Nuclear Medicine, Bern University Hospital, Bern, Switzerland
- School of Psychology and Counseling, Queensland University of Technology, Brisbane, Australia
| | - G Hefner
- Vitos Clinic for Forensic Psychiatry, Forensic Psychiatry, Eltville, Germany
| | - A Frajerman
- Université Paris-Saclay, AP-HP, Service Hospitalo-Universitaire de Psychiatrie, Hôpital de Bicêtre
- Equipe MOODS, Inserm U1018, CESP (Centre de Recherche en Epidémiologie et Sante des Populations), Le Kremlin-Bicêtre, France
| | - O Howes
- Department of Psychosis Studies, IoPPN, King's College London, De Crespigny Park, London, SE5 8AF, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - M Jukic
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia and Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - E Kim
- Department of Psychiatry, Seoul National University College of Medicine, Republic of Korea
| | - S Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Republic of Korea
| | - I Manisalco
- Dipartimento di Psichiatria, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - S Moriguchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - D J Müller
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - S Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - M Osugo
- Department of Psychosis Studies, IoPPN, King's College London, De Crespigny Park, London, SE5 8AF, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - M Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University
- JARA - Translational Brain Medicine, Aachen, Germany; Alexianer Center for Mental Health, Aachen, Germany
| | - H G Ruhe
- Department of psychiatry, Radboudumc, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
| | - M Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - G Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland
| | - A Serretti
- Department of Medicine and Surgery, Kore University of Enna, Italy
| | - E Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - O Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway, and Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - W Steimer
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
| | - H S Süzen
- Department of Pharmaceutic Toxicology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - H Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - S Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - F Vandenberghe
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - C Verstuyft
- Department of Molecular Genetics, Pharmacogenetics and Hormonology Bicêtre University Hospital Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, F-94275, France
- CESP, MOODS Team, INSERM UMR 1018, Medicine Faculty, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - G Zernig
- Department of Pharmacology, Medical University Innsbruck; Private Practice for Psychotherapy and Court-Certified Witness, Hall in Tirol, Austria
| | - C Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Germany
| | - C B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Department of Psychiatry, Centre for Psychiatric Neuroscience, Lausanne University Hospital, University of Lausanne, 1008 Prilly, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
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Leung JG, Allen ND, Markota M. A case series of clozapine titrations affected by inflammatory processes. Schizophr Res 2024; 268:94-97. [PMID: 37633777 DOI: 10.1016/j.schres.2023.08.007] [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: 05/28/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Jonathan G Leung
- Department of Pharmacy, Mayo Clinic Rochester, MN, United States of America.
| | - Nicholas D Allen
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, United States of America
| | - Matej Markota
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, United States of America
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Kumar Agrawal A, Das S, Abednego B Adre L, Raghuma N, Kaushik S, Adhikari A. A Case Report of a Patient with Soaring Clozapine Levels after Developing a Urinary Tract Infection. Case Rep Psychiatry 2024; 2024:9147674. [PMID: 38414905 PMCID: PMC10898943 DOI: 10.1155/2024/9147674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/29/2024] Open
Abstract
Clozapine is an antipsychotic medicine used to treat mental illnesses that is resistant to therapy. It can induce dose-dependent adverse effects such as increased susceptibility to infections and hematological irregularities. In this case report, we present a 37-year-old woman with schizoaffective disorder who experienced clozapine side effects following a moderate urinary tract infection (UTI). Her serum clozapine levels and side effects were increased throughout her UTI but resolved once the UTI was managed conservatively. We reviewed clozapine's pharmacokinetic properties to understand why serum levels rose during infection. While we could not definitely explain the mechanism of elevation, we emphasize the importance of monitoring serum clozapine levels and keeping watchful for adverse effects, as well as heightened scrutiny, evaluation for recent infections, and regular monitoring of patients.
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Affiliation(s)
| | - Soumitra Das
- Department of Psychiatry, Western Health, Victoria, Australia
| | | | - Nakka Raghuma
- GSL Medical College and General Hospital, Rajahmundry, India
| | - Sharanya Kaushik
- Bangalore Medical College and Research Institute, Bengaluru, India
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6
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Kuzin M, Gardin F, Götschi M, Xepapadakos F, Kawohl W, Seifritz E, Trauzeddel A, Paulzen M, Schoretsanitis G. Changes in Psychotropic Drug Blood Levels After SARS-CoV-2 Vaccination: A Two-Center Cohort Study. Ther Drug Monit 2023; 45:792-796. [PMID: 37296505 DOI: 10.1097/ftd.0000000000001118] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Limited evidence from case reports suggests that coronavirus disease 2019 (COVID-19) vaccination may interact with the treatment outcomes of psychiatric medications. Apart from clozapine, reports on the effect of COVID-19 vaccination on other psychotropic agents are scarce. This study aimed to investigate the impact of COVID-19 vaccination on the plasma levels of different psychotropic drugs using therapeutic drug monitoring. METHODS Plasma levels of psychotropic agents, including agomelatine, amisulpride, amitriptyline, escitalopram, fluoxetine, lamotrigine, mirtazapine, olanzapine, quetiapine, sertraline, trazodone, and venlafaxine, from inpatients with a broad spectrum of psychiatric diseases receiving COVID-19 vaccinations were collected at 2 medical centers between 08/2021 and 02/2022 under steady-state conditions before and after vaccination. Postvaccination changes were estimated as a percentage of baseline. RESULTS Data from 16 patients who received COVID-19 vaccination were included. The largest changes in plasma levels were reported for quetiapine (+101.2%) and trazodone (-38.5%) in 1 and 3 patients, respectively, 1 day postvaccination compared with baseline levels. One week postvaccination, the plasma levels of fluoxetine (active moiety) and escitalopram increased by 31% and 24.9%, respectively. CONCLUSIONS This study provides the first evidence of major changes in the plasma levels of escitalopram, fluoxetine, trazodone, and quetiapine after COVID-19 vaccination. When planning COVID-19 vaccination for patients treated with these medications, clinicians should monitor rapid changes in bioavailability and consider short-term dose adjustments to ensure safety.
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Affiliation(s)
- Maxim Kuzin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Fabian Gardin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - Markus Götschi
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - Franziskos Xepapadakos
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Wolfram Kawohl
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | | | - Michael Paulzen
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- Alexianer Hospital Aachen, Aachen, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA-Translational Brain Medicine, Aachen, Germany
| | - Georgios Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, New York, New York; and
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
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7
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Kersting XAK, Momtahen N, Lieb K. Clozapine Serum Concentrations Are Disrupted by SARS-CoV-2 Vaccinations. Case Rep Psychiatry 2023; 2023:9914879. [PMID: 38058314 PMCID: PMC10696469 DOI: 10.1155/2023/9914879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023] Open
Abstract
This paper reports the case of a 27-year-old man with paranoid schizophrenia who was finally stabilized on clozapine medication. After vaccination against severe acute respiratory syndrome coronavirus 2, serum levels of clozapine increased. It is well established that immune responses can trigger cytokine cascades affecting drug metabolism, which, in the case of clozapine treatment, can lead to severe intoxication.
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Affiliation(s)
- Xenia A. K. Kersting
- Department of Psychiatry and Psychotherapy, Johannes Gutenberg University Medical Center Mainz, Untere Zahlbacher Straße 8, 55131, Mainz, Germany
| | - Nicoletta Momtahen
- Department of Psychiatry and Psychotherapy, Johannes Gutenberg University Medical Center Mainz, Untere Zahlbacher Straße 8, 55131, Mainz, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, Johannes Gutenberg University Medical Center Mainz, Untere Zahlbacher Straße 8, 55131, Mainz, Germany
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8
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Kuzin M, Boeglin C, Schoretsanitis G, Pannu M, Kawohl W, Xepapadakos F. Letter to the editor: Clozapine plasma levels under co-medication with fluvoxamine during COVID-19 infection: A case report. Schizophr Res 2023; 261:110-112. [PMID: 37717507 DOI: 10.1016/j.schres.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Maxim Kuzin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland; Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany; University of Nicosia Medical School, Nicosia, Cyprus.
| | - Carla Boeglin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland
| | - Georgios Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-Work Group "Therapeutic Drug Monitoring", Nürnberg, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland; The Zucker Hillside Hospital, Department of Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | | | - Wolfram Kawohl
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland; University of Nicosia Medical School, Nicosia, Cyprus; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Franziskos Xepapadakos
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil am See, Zurich, Switzerland; University of Nicosia Medical School, Nicosia, Cyprus
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9
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Nakamura M, Nagamine T. Omicron Variant Infection May Not Exert an Influence on Serum Levels of Clozapine. J Clin Psychopharmacol 2023; 43:475-476. [PMID: 37683246 DOI: 10.1097/jcp.0000000000001733] [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] [Indexed: 09/10/2023]
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10
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Kowalski K, Misiak B. Schizophrenia and the COVID-19 pandemic: A narrative review from the biomedical perspective. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2023:S1888-9891(23)00015-0. [PMID: 37544807 DOI: 10.1016/j.rpsm.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/29/2023] [Accepted: 04/12/2023] [Indexed: 08/08/2023]
Abstract
The outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic in 2020 caused a rapid worsening of global mental health. Patients with severe mental disorders, including schizophrenia, are at higher risk of being infected. The neuroinvasive potential of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has been confirmed. The aim of this article was to present a narrative and comprehensive review of multidimensional associations between schizophrenia and COVID-19 with special emphasis on common biological pathways. Online searches were performed in the PubMed database and covered the publication period until September 17, 2022. Search terms included "psychosis", "schizophrenia", "inflammation" and "COVID-19". Viewed as a neuroinflammatory state, schizophrenia shares several neurobiological mechanisms with the COVID-19. Environmental stress, common comorbidities of schizophrenia and adverse effects of antipsychotic treatment are associated with the higher severity and mortality of the COVID-19. Additionally, more frequent relapses of psychosis have been observed, and might be related to lower treatment adherence. In the context of clinical manifestation, higher level of negative symptoms has been identified among patients with schizophrenia during the pandemic. Improvements in mental health care policy and treatment adjustment are necessary to protect people with schizophrenia who are the population that is particularly vulnerable to the consequences of the COVID-19 pandemic. Future research will show if prenatal infection with the SARS-CoV-2 increases a risk of psychosis.
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Affiliation(s)
- Krzysztof Kowalski
- Department of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland.
| | - Błażej Misiak
- Department of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
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11
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Bozkurt I, Gözler T, Yüksel I, Ulucan K, Tarhan KN. Prognostic Value of CYP1A2 (rs2069514 and rs762551) Polymorphisms in COVID-19 Patients. Balkan J Med Genet 2023; 26:35-42. [PMID: 37576788 PMCID: PMC10413886 DOI: 10.2478/bjmg-2023-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
The aim of the study was to examine the genotype-allele determination of CYP1A2 rs2069514 and rs762551 polymorphisms in patients with mild and severe COVID-19 and to determine their effectiveness as prognostic criteria in COVID-19. The study consists of 60 patients who were hospitalized in intensive care or outpatient treatment due to COVID-19 in Istanbul NP Brain Hospital between 2020-2021. Genotyping was conducted by Real-Time PCR. Age (p<0.001); chronic disease (p=0.002); cardiovascular disease (p=0.004); respiratory distress (p<0.001); neurological disease (p=0.004); fatigue (p=0.048); loss of taste and smell (p=0.003); nausea/vomiting (p=0.026); intubated (p<0.001); ground glass image (p<0.001) and CYP1A2 genotypes (p<0.001) showed a statistically significant difference between patients with and without intensive care admission. According to multivariate logistic regression analysis, CYP1A2 *1A/*1C + *1C/*1C genotypes (OR:5.23 95% CI: 1.22-22.36; p=0.025), chronic disease (OR:4.68 95% CI:1.14-19.15; p=0.032) or patients at 65 years or older (OR:5.17, 95%CI:1.26-21.14; p=0.022) increased the risk of admission to the intensive care unit. According to our results, we strongly suggest considering the CYP1A2 rs2069514 and rs762551 polymorphisms as important predictors of Intensive Care Unit admission in patients with COVID-19, and we also suggest that genotype results will guide clinicians for the benefit and the efficiency of the treatment.
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Affiliation(s)
- I Bozkurt
- Department of Medical Biochemistry, Faculty of Medicine, Üsküdar University, Istanbul, Turkey
| | - T Gözler
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Faculty of Medicine, Üsküdar University, Istanbul, Turkey
| | - I Yüksel
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Faculty of Medicine, Üsküdar University, Istanbul, Turkey
| | - K Ulucan
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Faculty of Medicine, Üsküdar University, Istanbul, Turkey
- Department of Medical Biology and Genetics, Faculty of Dentistry, Marmara University, Istanbul, Turkey
| | - KN Tarhan
- Uskudar University NP Hospital, Istanbul, Turkey
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12
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Leung JG. Part
II
: Interactive case—Clinical pearls of clozapine. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023. [DOI: 10.1002/jac5.1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Ansari S, Kelbrick M, Paduret G, Diaz N, Menzel R, Rogers R, Wareham C, Griffiths C, Jugon S, Tidy K, Johnson S, Mann N, Tanner J, Millward T, Latif S. Clinical practice guideline for clozapine use in patients with
COVID
‐19. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2023. [DOI: 10.1002/pnp.779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Saba Ansari
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Marlene Kelbrick
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Gabriela Paduret
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Natasha Diaz
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Rose Menzel
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Rowena Rogers
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Claire Wareham
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Chris Griffiths
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Sue Jugon
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Katy Tidy
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Sara Johnson
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Nick Mann
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - James Tanner
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Tim Millward
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Shahid Latif
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
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McColl ER, Croyle MA, Zamboni WC, Honer WG, Heise M, Piquette-Miller M, Goralski KB. COVID-19 Vaccines and the Virus: Impact on Drug Metabolism and Pharmacokinetics. Drug Metab Dispos 2023; 51:130-141. [PMID: 36273826 PMCID: PMC11022893 DOI: 10.1124/dmd.122.000934] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 01/08/2023] Open
Abstract
This article reports on an American Society of Pharmacology and Therapeutics, Division of Drug Metabolism and Disposition symposium held at Experimental Biology on April 2, 2022, in Philadelphia. As of July 2022, over 500 million people have been infected with SARS-CoV-2 (the virus causing COVID-19) and over 12 billion vaccine doses have been administered. Clinically significant interactions between viral infections and hepatic drug metabolism were first recognized over 40 years ago during a cluster of pediatric theophylline toxicity cases attributed to reduced hepatic drug metabolism amid an influenza B outbreak. Today, a substantive body of research supports that the activated innate immune response generally decreases hepatic cytochrome P450 activity. The interactions extend to drug transporters and other organs and have the potential to impact drug absorption, distribution, metabolism, and excretion (ADME). Based on this knowledge, altered ADME is predicted with SARS-CoV-2 infection or vaccination. The report begins with a clinical case exploring the possibility of SARS-CoV-2 vaccination increasing clozapine levels. This is followed by discussions of how SARS-CoV-2 infection or vaccines alter the metabolism and disposition of complex drugs, such as nanoparticles and biologics and small molecule therapies. The review concludes with a discussion of the effects of viral infections on placental amino acid transport and their potential to impact fetal development. The session improved our understanding of the impact of emerging viral infections and vaccine technologies on drug metabolism and disposition, which will help mitigate drug toxicity and improve drug and vaccine safety and effectiveness. SIGNIFICANCE STATEMENT: Altered pharmacokinetics of small molecule and complex molecule drugs and fetal brain distribution of amino acids following SARS-CoV-2 infection or immunization are possible. The proposed mechanisms involve decreased liver cytochrome P450 metabolism of small molecules, enhanced innate immune system metabolism of complex molecules, and altered placental and fetal blood-brain barrier amino acid transport, respectively. Future research is needed to understand the effects of these interactions on adverse drug responses, drug and vaccine safety, and effectiveness and fetal neurodevelopment.
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Affiliation(s)
- Eliza R McColl
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - Maria A Croyle
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - William C Zamboni
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - William G Honer
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - Mark Heise
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - Micheline Piquette-Miller
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
| | - Kerry B Goralski
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (E.R.M., M.P-M.); Department of Molecular Pharmaceutics and Drug Delivery and LaMontagne Center for Infectious Disease, University of Texas at Austin, College of Pharmacy, Austin, Texas (M.A.C.); Eshelman School of Pharmacy (W.C.Z.) and Department of Genetics, Department of Microbiology and Immunology, and The Rapidly Emerging Antiviral Drug Development Initiative (READDI) (M.H.), University of North Carolina, Chapel Hill, North Carolina; Department of Psychiatry, University of British Columbia and British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada (W.G.H.); and College of Pharmacy, Faculty of Health and Department of Pharmacology and Department of Pediatrics, Faculty of Medicine, Dalhousie University (K.B.G.); Division of Pediatric Hematology and Oncology, Department of Pediatrics, IWK Health Centre (K.B.G.); and Beatrice Hunter Cancer Research Institute (K.B.G.), Halifax, Nova Scotia, Canada
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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The Modernization of Clozapine: A Recapitulation of the Past in the United States and the View Forward. J Clin Psychopharmacol 2022; 42:565-580. [PMID: 36170148 DOI: 10.1097/jcp.0000000000001606] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Although clozapine was Food and Drug Administration (FDA) approved more than 3 decades ago, major barriers and gaps in knowledge continue to prevent its effective and safe use. We review modern-day problems encountered with clozapine in the United States (US). METHODS Information surrounding current administrative, clinical, research, and technological gaps or barriers related to clozapine use in the US was reviewed. FINDINGS The history of how clozapine became FDA approved likely contributes to gaps in knowledge. The frequency of safety warnings added to the FDA prescribing information may add to fears about clozapine, as evidence by numerous published survey studies. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program has been modified several times in the last decade, causing access and safety issues for patients, which are discussed. Evidence may suggest that the FDA REMS requirements for hematologic monitoring are too cumbersome, and there may be ability to safely loosen requirements. The COVID-19 pandemic brought forth the ability for extended interval monitoring but also greater awareness of the clozapine-inflammation interaction. Newer guidelines published describe considerations in personalizing clozapine titration based on principles of ethnopsychopharmacology. Emerging technologies to support the use of clozapine are not widely available. IMPLICATIONS Clozapine is a unique life-saving drug but it is underused in the US, despite its established efficacy. The 2021 REMS changes led to significant difficulties for providers and patients. We highlight the importance of the clozapine-inflammation interaction, therapeutic drug monitoring, and the ability for individual care based on patient-specific factors. There is an urgent need for advancing technology used for clozapine monitoring, evaluating barriers created by REMS, and establishing consistent practices throughout the US.
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Giles G, Varghese S, Shymko G, Nguyen T, Waters F. Clozapine Therapy and COVID-19: A Systematic Review of the Prevalence Rates, Health Outcomes, Hematological Markers, and Patient Perspectives. Schizophr Bull 2022; 49:53-67. [PMID: 36242537 PMCID: PMC9620749 DOI: 10.1093/schbul/sbac148] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND/OBJECTIVES There have been concerns that clozapine treatment may undermine the capacity of the body to fight infection and increase the vulnerability to contracting COVID-19. This review of recent cohort studies investigated (1) whether people with a severe psychiatric disorder are at increased risk of COVID-19 and complications, (2) the immunological response of clozapine-users who contract COVID-19, and (3) patients' perspectives on COVID-19 and the pandemic response. METHODS A systematic search of EMBASE, Medline, Pubmed, and PsycINFO databases using PRISMA guidelines using "COVID-19", "clozapine", and "vaccination" terms. RESULTS 18 studies (out of 330 identified) met all criteria (N = 119 054 including 8045 on clozapine). There was no strong evidence that clozapine users may be at increased risk of contracting COVID-19 or developing complications after adjusting for medical comorbidities. Hematological studies showed temporary reductions in neutrophils in COVID-19-positive patients and vaccination suggesting a clozapine effect in defence against infection. Vaccination studies did not report major adverse effects. Increased plasma levels of clozapine and neutropenia however point to COVID-19-related interference of clozapine metabolism. Patient surveys reported limited impact on mental health and positive attitudes regarding pandemic response. CONCLUSION This review did not find compelling evidence that the immune system of clozapine users put them at risk of COVID-19 and further complications. Evidence of drug-infection interactions however points to the importance of adhering to consensus guidelines about clozapine therapy during the pandemic. More evidence using longitudinal designs is required to examine the longer-term effects of COVID-19 and vaccination in this vulnerable population.
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Affiliation(s)
- Grace Giles
- To whom correspondence should be addressed; Peel and Rockingham Kwinana Mental Health Service, Elanora Drive, Cooloongup, Western Australia, 6168, Australia; tel: 08 95994933, fax: 08 95994966, e-mail:
| | - Sunny Varghese
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Gordon Shymko
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Thinh Nguyen
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia,Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia
| | - Flavie Waters
- Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia,School of Psychological Sciences, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia,Clinical Research Centre, Graylands Hospital Campus, North Metropolitan Area Services-Mental Health, Brockway Road, Mount Claremont, Perth, Western Australia, 6010, Australia
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Neutropenia in Patients With Clozapine-Treated Schizophrenia: An Effect of Clozapine or a Consequence of SARS-CoV-2 Infection? A Systematic Review. Am J Ther 2022; 29:e544-e552. [PMID: 35749754 DOI: 10.1097/mjt.0000000000001532] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clozapine is the only approved antipsychotic for treatment-resistant schizophrenia. Despite its therapeutic benefits, it is still widely underused, mainly because of its potential to cause agranulocytosis and neutropenia. Prescribing clozapine in COVID-19-positive patients became more challenging because of this potential side effect. This article is a review of literature on the risk of neutropenia associated with clozapine treatment in patients with COVID-19. AREAS OF UNCERTAINTY In clozapine-treated COVID-19-positive patients, neutropenia was reported in some cases; is it a consequence of clozapine treatment or of SARS-Co2 infection? DATA SOURCES Data were extracted from 2 databases: PubMed/MEDLINE and Google Scholar. We selected all original reports, from March 2020 until May 2022, on neutropenia associated with clozapine treatment in positive COVID-19 patients. Eleven studies were selected for the final analysis. THERAPEUTIC ADVANCES Before the COVID-19 pandemic, neutropenia in clozapine-treated patients was reported in 3.8% of cases. During the pandemic, neutropenia rates seemed to be higher. As per the cause of neutropenia, studies reported contradictory results. We aim to clarify rates and causes of neutropenia in clozapine-treated COVID-19-positive patients. RESULTS Three hundred eighty-eight articles were initially selected from the 2 databases. After excluding duplicates, unrelated articles, reviews, and guidelines, 11 studies were analyzed, all centered on clozapine treatment, COVID-19 infection, and associated neutropenia. CONCLUSIONS Clozapine treatment in COVID-19-positive patients may be associated with a transient reduction of absolute neutrophils count, in some cases reaching neutropenia levels. Neutropenia rates reported in SARS-CoV-2-infected patients are higher than the prepandemic reports; therefore, we assume that the cause might be a result of the immunological interference between clozapine and SARS-CoV-2. Clozapine treatment needs to be continued whenever possible, with dose adjustments in relation to blood test results.
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Arrojo-Romero M, Codesido-Barcala MR, de Leon J. Un brote por Covid-19 en un hospital psiquiátrico de larga estancia dio a lugar a infecciones en 6 pacientes en tratamiento con clozapina: elevaciones en los niveles plasmáticos de clozapine. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2022; 15:290-292. [PMID: 35782582 PMCID: PMC9233870 DOI: 10.1016/j.rpsm.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Leung JG, Rakosevic DB, Courtis SN, Leloux MR, Allen ND. Iatrogenic clozapine intoxication following hospital admission: a case-based rationale for an inpatient pharmacy clozapine monitoring service. J Am Pharm Assoc (2003) 2022; 62:1711-1716. [DOI: 10.1016/j.japh.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022]
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Jafry R, Kelbrick M. COVID
‐19 and clozapine use in an early intervention for psychosis service. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2022. [DOI: 10.1002/pnp.737] [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]
Affiliation(s)
- Rizwana Jafry
- Dr Jafry is an ST6, General Adult Psychiatry and Dr Kelbrick is a Consultant Psychiatrist, both at Northamptonshire Healthcare NHS Foundation Trust, UK
| | - Marlene Kelbrick
- Dr Jafry is an ST6, General Adult Psychiatry and Dr Kelbrick is a Consultant Psychiatrist, both at Northamptonshire Healthcare NHS Foundation Trust, UK
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Davis EAK, Hightower T, Cinnamon KA. Toxic clozapine level as first indication of severe, acute infection. Ment Health Clin 2022; 12:45-48. [PMID: 35116212 PMCID: PMC8788300 DOI: 10.9740/mhc.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background Clozapine levels can be influenced by many factors, including pharmacogenomic variability, pharmacokinetic drug interactions, and infection/inflammation. The concentration-to-dose ratio (C/D), a measure of a medication's rate of metabolism and clearance, may increase during an acute infection due to decreased medication metabolism and clearance. Case Report A 56-year-old White man was restarted on clozapine and titrated up to 350 mg/d with therapeutic steady-state levels (C/D 1.11) on hospital day (HD) 69. At this time, he was also being treated for COPD exacerbation. For the next month, he continued to complain of cough, but vital signs and chest x-ray remained normal. Labs were unremarkable except for occasional leukocytosis that would resolve on repeat evaluation. A routine clozapine level drawn on HD 104, resulted on day 108 and showed clozapine toxicity with C/D 4.05, although the patient was asymptomatic. After receipt of labs on day 109, showing elevated WBC count, he was immediately sent to the emergency room where he was admitted for treatment of pneumonia. On return to the state hospital, the patient was continued on 100 mg clozapine and titrated to 200 mg/d based on low drug levels. He continued to do well on 200 mg/d clozapine with C/D averaging 1.13 (range, 0.75-1.52). Discussion Acute infection and illness can lead to significantly increased clozapine levels and toxicity, even if symptoms of toxicity are minimal or absent. This appears to be the first report of a toxic level being the first indication of severe medical illness.
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Affiliation(s)
| | - Tyler Hightower
- Psychiatrist and Director of Forensic Services, Springfield Hospital Center, Sykesville, Maryland
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Vita A, Barlati S. The impact of the Covid-19 pandemic on patients with schizophrenia. Eur Neuropsychopharmacol 2022; 54:62-64. [PMID: 34462180 PMCID: PMC8363471 DOI: 10.1016/j.euroneuro.2021.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia; Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy.
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia; Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
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Arrojo-Romero M, Codesido-Barcala MR, de Leon J. A Covid-19 outbreak in a Spanish long-term psychiatric hospital led to infections in 6 clozapine patients: elevations in their plasma clozapine levels. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2022; 15:290-292. [PMID: 36513405 PMCID: PMC9734288 DOI: 10.1016/j.rpsmen.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/09/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain,Corresponding author
| | | | - 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
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Tomita T, Sakamoto Y, Saito M, Hashimoto K, Ono Y, Nakamura K. Two Patients with Schizophrenia Treated with Clozapine Developed Neutropenia After Receiving a COVID-19 Vaccine. Int Med Case Rep J 2022; 15:29-33. [PMID: 35115846 PMCID: PMC8805838 DOI: 10.2147/imcrj.s350879] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/20/2022] [Indexed: 01/22/2023] Open
Affiliation(s)
- Tetsu Tomita
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
- Correspondence: Tetsu Tomita, Tel +81-172 39 5066, Fax +81-172 39 5067, Email
| | - Yui Sakamoto
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Manabu Saito
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Kojiro Hashimoto
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Yasuki Ono
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Kazuhiko Nakamura
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
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Elevated Clozapine Blood Concentrations After Second COVID-19 Vaccination With Spikevax (COVID-19 Vaccine Moderna). J Clin Psychopharmacol 2022; 42:317-320. [PMID: 35091524 PMCID: PMC9042212 DOI: 10.1097/jcp.0000000000001522] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ohlis A, Sörberg Wallin A, Sarafis A, Sjöqvist H, MacCabe JH, Ahlen J, Dalman C. Clozapine treatment and risk of severe COVID-19 infection. Acta Psychiatr Scand 2022; 145:79-85. [PMID: 34676888 PMCID: PMC8653206 DOI: 10.1111/acps.13379] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID-19 infection as compared with patients on other antipsychotic drugs. METHODS In this register-based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from 1 March 2020 to 14 January 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID-19 infection) were: inpatient care, care within intensive care unit or death due to COVID-19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. CONCLUSIONS Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID-19 pandemic with careful monitoring and readiness to alter drug doses as needed.
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Affiliation(s)
- Anna Ohlis
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Alma Sörberg Wallin
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Anna Sarafis
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Hugo Sjöqvist
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - James H. MacCabe
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - Johan Ahlen
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
| | - Christina Dalman
- Department of Global Public HealthKarolinska InstitutetStockholmSweden,Centre for Epidemiology and Community MedicineStockholm County CouncilStockholmSweden
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Veerman SRT, Bogers JPAM, Cohen D, Schulte PFJ. COVID-19: Risks, Complications, and Monitoring in Patients on Clozapine. PHARMACOPSYCHIATRY 2021; 55:48-56. [PMID: 34470068 DOI: 10.1055/a-1562-2521] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Dutch Clozapine Collaboration Group is frequently asked for advice about the management of clozapine-treated patients when infected with or vaccinated against SARS-CoV-2. We provide state of the art information about the risks of SARS-CoV-2 infection for patients on clozapine and we give advice on measures to be taken, especially in regard to the monitoring of clozapine plasma levels, WBC count and differentiation during COVID-19 and after vaccination. We present an overview of relevant editorials, observational studies, and case studies, in which COVID-19 was reported in patients on clozapine. Patients using clozapine may have a higher risk of infection than patients with schizophrenia spectrum disorders (SSD) using other antipsychotics. SARS-CoV-2 infection can result in a dangerous increase of clozapine plasma levels, and granulocytopenia and lymphocytopenia (generally mild and short-term) may also occur, usually not as a result of clozapine treatment. Clozapine intoxication, pneumonia and delirium are the main complications of COVID-19 in patients on clozapine. In order to prevent clozapine intoxication, reduction of the original dose by half is generally recommended in clozapine users who contract COVID-19. When a cytokine storm is suspected in an advanced stage of COVID-19, reduction by three quarters seems more appropriate. If COVID-19 patients on clozapine develop granulocytopenia, SARS-CoV-2, rather than clozapine, should be considered as the cause. Schizophrenia patients in general and clozapine users in particular belong to a high-risk group that warrants early vaccination on a medical indication.
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Affiliation(s)
- Selene R T Veerman
- MHO Noord-Holland Noord and the Dutch Clozapine Collaboration Group, Netherland
| | - Jan P A M Bogers
- MHO Rivierduinen and the Dutch Clozapine Collaboration Group, Netherland
| | - Dan Cohen
- MHO Noord-Holland Noord and the Dutch Clozapine Collaboration Group, Netherland
| | - Peter F J Schulte
- MHO Noord-Holland Noord and the Dutch Clozapine Collaboration Group, Netherland
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Edinoff AN, Fort JM, Woo JJ, Causey CD, Burroughs CR, Cornett EM, Kaye AM, Kaye AD. Selective Serotonin Reuptake Inhibitors and Clozapine: Clinically Relevant Interactions and Considerations. Neurol Int 2021; 13:445-463. [PMID: 34564289 PMCID: PMC8482107 DOI: 10.3390/neurolint13030044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/29/2021] [Accepted: 08/12/2021] [Indexed: 12/21/2022] Open
Abstract
The monoamine hypothesis of depression attributes the symptoms of major depressive disorders to imbalances of serotonin, noradrenaline, and dopamine in the limbic areas of the brain. The preferential targeting of serotonin receptor (SERT) by selective serotonin reuptake inhibitors (SSRIs) has offered an opportunity to reduce the range of these side effects and improve patient adherence to pharmacotherapy. Clozapine remains an effective drug against treatment-resistant schizophrenia, defined as failing treatment with at least two different antipsychotic medications. Patients with schizophrenia who display a constellation of negative symptoms respond poorly to antipsychotic monotherapy. Negative symptoms include the diminution of motivation, interest, or expression. Conversely to the depressive symptomology of interest presently, supplementation of antipsychotics with SSRIs in schizophrenic patients with negative symptoms lead to synergistic improvements in the function of these patients. Fluvoxamine is one of the most potent inhibitors of CYP1A2 and can lead to an increase in clozapine levels. Similar increases in serum clozapine were detected in two patients taking sertraline. However, studies have been contradictory as well, showing no such increases, which are worrying. Clinicians should be aware that clozapine levels should be monitored with any coadministration with SSRIs.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71103, USA
| | - Juliana M Fort
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71103, USA
| | - Joshua J Woo
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Christopher D Causey
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Caroline R Burroughs
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport, Shreveport, LA 71103, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport, Shreveport, LA 71103, USA
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Clozapine-related immunodeficiency: Implications for Parkinson's disease psychosis in the context of the COVID-19 pandemic. Rev Neurol (Paris) 2021; 177:849-851. [PMID: 34217512 PMCID: PMC8221910 DOI: 10.1016/j.neurol.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 12/29/2022]
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Törnquist K, Asghar MY, Srinivasan V, Korhonen L, Lindholm D. Sphingolipids as Modulators of SARS-CoV-2 Infection. Front Cell Dev Biol 2021; 9:689854. [PMID: 34222257 PMCID: PMC8245774 DOI: 10.3389/fcell.2021.689854] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/25/2021] [Indexed: 12/17/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of the COVID-19 pandemic with severe consequences for afflicted individuals and the society as a whole. The biology and infectivity of the virus has been intensively studied in order to gain a better understanding of the molecular basis of virus-host cell interactions during infection. It is known that SARS-CoV-2 binds to angiotensin-converting enzyme 2 (ACE2) via its spike protein. Priming of the virus by specific proteases leads to viral entry via endocytosis and to the subsequent steps in the life cycle of SARS-CoV-2. Sphingosine and ceramide belong to the sphingolipid family and are abundantly present in cell membranes. These lipids were recently shown to interfere with the uptake of virus particles of SARS-CoV-2 into epithelial cell lines and primary human nasal cells in culture. The mechanisms of action were partly different, as sphingosine blocked, whilst ceramide facilitated viral entry. Acid sphingomyelinase (ASM) is vital for the generation of ceramide and functional inhibition of ASM by drugs like amitriptyline reduced SARS-CoV-2 entry into the epithelial cells. Recent data indicates that serum level of sphingosine-1-phosphate (S1P) is a prognostic factor for COVID-2 severity. Further, stimulation of sphingosine-1-phosphate receptor 1 (S1PR1) might also constrain the hyper-inflammatory conditions linked to SARS-CoV-2. Here, we review recent exciting findings regarding sphingolipids in the uptake of SARS-CoV-2 and in the course of COVID-19 disease. More studies are required on the mechanisms of action and the potential use of antidepressant drugs and sphingolipid modifiers in SARS-CoV-2 infections and in the treatment of the more serious and fatal consequences of the disease.
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Affiliation(s)
- Kid Törnquist
- Minerva Foundation Institute for Medical Research, Helsinki, Finland.,Faculty of Science and Engineering, Cell Biology, Åbo Akademi University, Turku, Finland
| | | | - Vignesh Srinivasan
- Minerva Foundation Institute for Medical Research, Helsinki, Finland.,Medicum, Department of Biochemistry and Developmental Biology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Laura Korhonen
- Department of Child and Adolescent Psychiatry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Dan Lindholm
- Minerva Foundation Institute for Medical Research, Helsinki, Finland.,Medicum, Department of Biochemistry and Developmental Biology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:ph14060514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 01/08/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs—Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021. [DOI: 10.3390/ph14060514
expr 938544256 + 801362328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Moschny N, Hefner G, Grohmann R, Eckermann G, Maier HB, Seifert J, Heck J, Francis F, Bleich S, Toto S, Meissner C. Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514&set/a 947965394+957477086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug's pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients' drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior-both clinically relevant in psychiatry-that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Affiliation(s)
- Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
- Correspondence: ; Tel.: +49-511-532-3656
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Str. 4, 65346 Eltville, Germany;
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaum-Str. 7, 80336 Munich, Germany;
| | - Gabriel Eckermann
- Department of Forensic Psychiatry and Psychotherapy, Hospital Kaufbeuren, Kemnater-Str. 16, 87600 Kaufbeuren, Germany;
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany;
| | - Flverly Francis
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Catharina Meissner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
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Thompson D, Delorme CM, White RF, Honer WG. Elevated clozapine levels and toxic effects after SARS-CoV-2 vaccination. J Psychiatry Neurosci 2021; 46:E210-E211. [PMID: 33667055 PMCID: PMC8061735 DOI: 10.1503/jpn.210027] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Deborah Thompson
- From Fraser Health Mental Health and Substance Use Services, Langley/Mission, BC, Canada (Thompson, Delorme); Department of Psychiatry, University of British Columbia, and BC Psychosis Program, Vancouver, BC, Canada (White, Honer); and BC Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada (Honer)
| | - Clay M Delorme
- From Fraser Health Mental Health and Substance Use Services, Langley/Mission, BC, Canada (Thompson, Delorme); Department of Psychiatry, University of British Columbia, and BC Psychosis Program, Vancouver, BC, Canada (White, Honer); and BC Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada (Honer)
| | - Randall F White
- From Fraser Health Mental Health and Substance Use Services, Langley/Mission, BC, Canada (Thompson, Delorme); Department of Psychiatry, University of British Columbia, and BC Psychosis Program, Vancouver, BC, Canada (White, Honer); and BC Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada (Honer)
| | - William G Honer
- From Fraser Health Mental Health and Substance Use Services, Langley/Mission, BC, Canada (Thompson, Delorme); Department of Psychiatry, University of British Columbia, and BC Psychosis Program, Vancouver, BC, Canada (White, Honer); and BC Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada (Honer)
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Clozapine. REACTIONS WEEKLY 2021. [PMCID: PMC7933392 DOI: 10.1007/s40278-021-92026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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