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Saatchi A, Zarkovic T, Borden S, Palaty J, Gill C. Therapeutic drug monitoring of clozapine in human serum by high-throughput paper spray mass spectrometry. J Mass Spectrom Adv Clin Lab 2024; 32:41-46. [PMID: 38419980 PMCID: PMC10899010 DOI: 10.1016/j.jmsacl.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Monitoring the atypical antipsychotic drug clozapine is crucial to ensure patient safety. This article showcases a high-throughput analytical method for measuring clozapine and its primary metabolite norclozapine (N-desmethylclozapine) in serum using paper spray mass spectrometry (PS-MS). Objectives This study aimed to assess the viability of a PS-MS method for the rapid measurement of clozapine and norclozapine in human serum samples as an alternative to liquid chromatography mass spectrometry (LC-MS). Methods Serum samples were processed by protein precipitation followed by deposition of the supernatant containing labelled internal standards onto paper spray substrates mounted in cartridges. Analytes were then analyzed using a triple quadrupole mass spectrometer equipped with a commercial paper spray ionization source. The results obtained from the patient samples were compared to those from a validated LC-MS assay. Results PS-MS calibrations for clozapine and norclozapine were linear (R2 > 0.99) over five days. Between-run precision was below 8 %, and within-run precision did not exceed 10 %. When compared to a validated LC-MS method, the mean bias for 39 patient samples was -9% for clozapine and -1% for norclozapine, with no outliers. Mass spectrometry ion ratio comparisons indicated no interference for patient samples above the lower limit of quantification. There was less than 7 % change in the measured concentrations of both analytes over five days for samples dried on paper substrates. Notably, virtually no maintenance of the MS source was required during this study. Conclusion This study illustrates the potential of PS-MS for serum drug monitoring in the clinical laboratory.
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Affiliation(s)
- A. Saatchi
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - T.M. Zarkovic
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - S.A. Borden
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - J. Palaty
- Fraser Health Authority, Vancouver, BC, Canada
| | - C.G. Gill
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
- Department of Chemistry, Simon Fraser University, Burnaby, BC, Canada
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
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Sahib Din J, Navarro Garcia E, Al-Rubaye H, Julian C. Knee Buckling as an Atypical Adverse Effect of Clozapine: A Case Report. Cureus 2024; 16:e55865. [PMID: 38595866 PMCID: PMC11002468 DOI: 10.7759/cureus.55865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Clozapine has become a widely popular and effective medication in the treatment of refractory schizophrenia and refractory bipolar disorder. Although the use of clozapine proves to be an effective resort, it has to be closely monitored due to its narrow therapeutic range and multiple dangerous adverse effects. In rare cases, clozapine has been known to cause an antagonistic myoclonic jerk that leads to knee buckling. Here, we present the case of a 29-year-old female who is being treated for schizoaffective disorder, bipolar, manic type, who reported two instances of knee buckling associated with falls while taking clozapine.
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Affiliation(s)
| | - Ernesto Navarro Garcia
- Nanotechnology, University of Central Florida, Orlando, USA
- Physiology and Neuroscience, St George's University, St. George's, GRD
| | - Hiba Al-Rubaye
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
| | - Carlos Julian
- Physiology and Neuroscience, St. George's University School of Medicine, St. George's, GRD
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3
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Kingston E, Tingle M, Bellissima BL, Helsby N, Burns K. CYP-catalysed cycling of clozapine and clozapine- N-oxide promotes the generation of reactive oxygen species in vitro. Xenobiotica 2024; 54:26-37. [PMID: 38108307 DOI: 10.1080/00498254.2023.2294473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Clozapine is an effective atypical antipsychotic indicated for treatment-resistant schizophrenia, but is under-prescribed due to the risk of severe adverse drug reactions such as myocarditis.A mechanistic understanding of clozapine cardiotoxicity remains elusive.This study aimed to investigate the contribution of selected CYP isoforms to cycling between clozapine and its major circulating metabolites, N-desmethylclozapine and clozapine-N-oxide, with the potential for reactive species production.CYP supersome™-based in vitro techniques were utilised to quantify specific enzyme activity associated with clozapine, clozapine-N-oxide and N-desmethylclozapine metabolism.The formation of reactive species within each incubation were quantified, and known intermediates detected.CYP3A4 predominately catalysed clozapine-N-oxide formation from clozapine and was associated with concentration-dependent reactive species production, whereas isoforms favouring the N-desmethylclozapine pathway (CYP2C19 and CYP1A2) did not produce reactive species.Extrahepatic isoforms CYP2J2 and CYP1B1 were also associated with the formation of clozapine-N-oxide and N-desmethylclozapine but did not favour one metabolic pathway over another.Unique to this investigation is that various CYP isoforms catalyse clozapine-N-oxide reduction to clozapine.This process was associated with the concentration-dependent formation of reactive species with CYP3A4, CYP1B1 and CYP1A1 that did not correlate with known reactive intermediates, implicating metabolite cycling and reactive oxygen species in the mechanism of clozapine-induced toxicity.
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Affiliation(s)
- Ellen Kingston
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Malcolm Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Nuala Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand
| | - Kathryn Burns
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
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Panić B, Jovanović M, Lukić V, Vučićević K, Miljković B, Milovanović S. Association of clozapine and norclozapine levels with patient and therapy characteristics-focus on interaction with valproic acid. Eur J Clin Pharmacol 2023; 79:1557-1564. [PMID: 37733278 DOI: 10.1007/s00228-023-03569-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE The goal of the study was to examine clozapine (CLZ) and norclozapine (NCLZ) therapeutic drug monitoring (TDM) data and associated sources of pharmacokinetic variability, particularly the impact of valproic acid (VPA) use. METHODS This study included 126 patients with psychiatric disorders on mono- or co-therapy with CLZ. Patients' data during routine TDM were collected retrospectively from clinical records. The descriptive and statistical analysis was computed using IBM SPSS Statistics software (version 22, NY, USA). Multiple linear regression, based on the last observations, was used to assess correlation between demographic characteristics, life habits and co-therapy with dose-corrected serum levels (C/D) of CLZ and NCLZ, as well as CLZ/NCLZ. RESULTS A total of 295 CLZ concentrations were measured in 126 patients, with a mean of 275.5 ± 174.4 µg/L, while 124 NCLZ concentrations were determined in 74 patients, with a mean of 194.6 ± 149.8 µg/L. A statistically significant effect on ln-transformed CLZ C/D was confirmed for sex and smoking, whereas sex, smoking and VPA therapy were associated with ln-transformed NCLZ C/D. According to the final models, lower values of NCLZ C/D for about 45.9% can be expected in patients receiving VPA. Concomitant use of VPA was the only factor detected to contribute in CLZ/NCLZ variability. CONCLUSION The results of this study may help clinicians interpret TDM data and optimize CLZ dosing regimens, especially in patients concomitantly treated with VPA. Our results show that VPA primarily decreases NCLZ levels, while alteration of the parent drug is not statistically significant.
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Affiliation(s)
- Bojana Panić
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Marija Jovanović
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia.
| | - Vera Lukić
- Institute of Forensic Medicine "Milovan Milovanović", Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Serbia
| | - Srđan Milovanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Psychiatry, University Clinical Center of Serbia, Belgrade, Serbia
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Tao Y, Wan R, Wang J, Liu Q, Tian M, Wang L, Yang Y, Zou Y, Luo Y, Ke F, Zhou Q, Wang D, Gao D. Carbonized human hair derived carbon dots for detection of clozapine. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 298:122803. [PMID: 37148662 DOI: 10.1016/j.saa.2023.122803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/27/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
Clozapine (CLZ) is known as the most effective antipsychotic medication for schizophrenia. However, low dosage or over dosage of CLZ is adverse to the treatment of Schizophrenia. Thus, it is necessary to develop effective detection method for CLZ. Recently, due to the advantages such as excellent optical properties, good photobleachability and sensitivity, carbon dots (CDs)-based fluorescent sensors for the detection of target analytes have drawn a great deal of attention. In this work, blue fluorescent CDs (Named as B-CDs) with quantum yield (QY) as high as 38% were obtained by using carbonized human hair as source material through one-step dialysis method for the first time. B-CDs showed obvious graphite-like structure with an average of 1.76 nm, containing abundant functional groups such as -C=O, amino N and C-N on the surface of carbon cores. Optical analysis showed that the B-CDs exhibited excitation-dependent emission property with maximum emission wavelength of 450 nm. Moreover, B-CDs were further applied as a fluorescence sensor to the detection of CLZ. The B-CDs based sensor exhibited a good quenching response by CLZ through the inner filter effect and static quenching mechanism with a limit of detection of 67 ng/mL, which was much lower than the minimal effective concentration in blood (0.35 μg/mL). Finally, to test the practical application value of the developed fluorescence method, the determination of the content of CLZ in tablets and the concentration in blood was carried out. Compared with the results of high-performance liquid chromatography (HPLC) method, it can be found that the constructed fluorescence detection method showed high accuracy and had great application potential in the detection of CLZ. Additionally, the results of cytotoxicity experiment showed that B-CDs had low cytotoxicity, which laid the foundation for the subsequent application of B-CDs in biological systems.
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Affiliation(s)
- Yongqing Tao
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Runlan Wan
- School of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Junji Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Qiuyi Liu
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Meng Tian
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Luchun Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yulian Yang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yuemeng Zou
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yuanning Luo
- School of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Famin Ke
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Quan Zhou
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Dandan Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Die Gao
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China.
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De Las Cuevas C, Sanz EJ, Villasante-Tezanos AG, de Leon J. Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in VigiBase. Expert Opin Drug Metab Toxicol 2023; 19:57-74. [PMID: 36920343 DOI: 10.1080/17425255.2023.2192401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Antipsychotics (APs), during treatment or overdose, may be associated with respiratory aspiration. AREAS COVERED A PubMed search on September 30, 2022, provided 3 cases of respiratory aspiration during clozapine therapy and 1 case during an AP overdose. VigiBase records of respiratory aspiration associated with APs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC). EXPERT OPINION The ICs (and IC025) were 2.1 (and 2.0) for APs, 3.2 (and 3.0) for clozapine, 2.6 (and 2.4) for quetiapine, and 2.5 (and 2.2) for olanzapine. Cases of respiratory aspiration associated with APs included: 137 overdose/suicide cases (64 fatal) and 609 cases during treatment (385 fatal) including 333 taking clozapine (238 fatal). In logistic regression models of fatal outcomes, the odds ratios, OR, and (95% confidence intervals, CI) of significant independent variables were: a) 2.3 - 2.6 for clozapine in 3 samples of AP treatment of varying size, b) 1.9 (CI 1.0 to 3.5) for geriatric age in 284 patients on clozapine treatment, and c) 1.8 (CI 1.1 - 3.2) for antidepressant co-medication in 276 patients on non-clozapine APs. Multiple AP pharmacological mechanisms may explain respiratory aspiration.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain.,Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain.,Hospital Universitario de Canarias, Tenerife, Spain
| | - Alejandro G Villasante-Tezanos
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, United States
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, United States.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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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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8
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Feasibility and Effect of Increasing Clozapine Plasma Levels in Long-Stay Patients With Treatment-Resistant Schizophrenia. J Clin Psychopharmacol 2023; 43:97-105. [PMID: 36825865 DOI: 10.1097/jcp.0000000000001657] [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] [Indexed: 02/25/2023]
Abstract
BACKGROUND It is unknown whether increasing the clozapine plasma level to 400, 750, or even 1000 ng/mL is a feasible and effective strategy in patients with treatment-resistant schizophrenia (TRS). We investigated this in long-stay patients with TRS. METHODS In long-stay TRS patients, doses of clozapine were increased gradually to reach target plasma levels of 400, 750, or 1000 ng/mL, depending on the clinical response and tolerability. After an effective or tolerated level was reached, positive and negative syndrome scale scores were evaluated after 3 months and 1 year. RESULTS Twenty-eight patients were included. Overall, 54% of the patients, and especially patients 60 years and older, could not achieve one of the clozapine target levels because of adverse effects. Three physically vulnerable patients died, probably not directly related to clozapine use. Although only 21% of patients achieved a more than 20% reduction in total symptoms at the 1-year follow-up, the mean severity of positive symptoms decreased from 18.18 to 15.10 ( P < 0.01). The largest decrease in positive symptoms was seen in TRS patients who achieved a plasma level of 750 ng/mL of clozapine. CONCLUSIONS Most TRS patients older than 60 years could not tolerate high clozapine levels and so this should not be attempted in older or otherwise physically vulnerable patients. Increasing clozapine levels to approximately 750 ng/mL in middle-aged patients with longstanding TRS may modestly reduce the severity of positive symptoms and improve the response rate.
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Santos RT, Mullen S, Crouse EL, Adams KS. Comparison of clozapine doses and tolerability in patients with and without concurrent valproic acid. Ment Health Clin 2023; 12:336-341. [PMID: 36644583 PMCID: PMC9819135 DOI: 10.9740/mhc.2022.12.336] [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] [Received: 03/07/2022] [Accepted: 09/14/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Valproic acid (VPA) and its various formulations can be given in conjunction with clozapine for seizure prophylaxis or for augmentation in schizophrenia. There is conflicting literature on how VPA affects clozapine metabolism and the incidence of clozapine-related side effects. The purpose of this study is to compare the effects of VPA when given concurrently with clozapine to patients on clozapine monotherapy. Methods A retrospective medical record review was completed to identify patients admitted to the inpatient psychiatry unit at an academic medical center with an order for clozapine with and without concurrent VPA from August 7, 2010 to August 7, 2020. The primary outcome was the difference in clozapine doses in patients on clozapine as monotherapy versus dual therapy with VPA. Secondary outcomes include the difference in incidence of adverse effects in monotherapy versus dual therapy, as well as clozapine and norclozapine concentrations in both treatment groups. Results During the study period, 73 patients were included in the monotherapy group and 35 patients were included in the dual therapy group. The average clozapine dose in the dual therapy group was 250 mg (95% CI = 194.7, 305.4) which was significantly higher than the average monotherapy dose of 175.9 mg (95% CI = 134.0, 208.7; P = .016). However, there was no significant difference in the average clozapine concentration between the dual therapy group (392.5 ng/mL; 95% CI = 252.8, 532.2) and monotherapy group (365.9 ng/mL; 95% CI = 260.5, 471.3; P = .756). There were higher rates of tachycardia (45.7% vs 17.8%; P = .002), sedation (51.4% vs 8.2%; P < .001), and constipation (42.8% vs 9.5%; P < .001) in the dual therapy group compared to the monotherapy group, respectively. Discussion Patients on concurrent clozapine and VPA received higher doses of clozapine and experienced a higher incidence of tachycardia, sedation, and constipation.
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Affiliation(s)
- Ranel Troy Santos
- PGY2 Resident, Virginia Commonwealth University Health System, Department of Pharmacy Services, Richmond, Virginia,
| | - Sandra Mullen
- Clinical Pharmacy Specialist, Virginia Commonwealth University Health System, Department of Pharmacy Services, Richmond, Virginia
| | - Ericka L. Crouse
- Associate Professor, Virginia Commonwealth University Health System, Department of Pharmacy Services, Richmond, Virginia
| | - Katie S. Adams
- Clinical Pharmacy Specialist, Virginia Commonwealth University Health System, Department of Pharmacy Services, Richmond, Virginia
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Lozano R, Bona C. Influence of Cigarette Smoking Habit on Clozapine-to-Norclozapine Ratio in Male Patients. J Res Pharm Pract 2023; 12:29-31. [PMID: 38213602 PMCID: PMC10779687 DOI: 10.4103/jrpp.jrpp_37_23] [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] [Received: 08/03/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2024] Open
Abstract
Objective This study aimed to evaluate the influence of cigarette smoking habit on the clozapine (CLZ)-to-norclozapine (norCLZ) ratio in male patients. Methods The sample consisted of plasma concentration of CLZ and norCLZ data set. The mean values of CLZ, norCLZ, and CLZ-to-norCLZ, between male patients who smoke versus nonsmokers were compared. Findings CLZ mean plasma level of 142 ± 80 ng/ml and 305 ± 159 ng/ml, norCLZ mean plasma level of 93 ± 72 ng/ml and 234 ± 62 ng/ml, and mean CLZ-to-norCLZ plasma level ratio of 2.1 ± 1.1 and 1.5 ± 0.5, were obtained respectively for male patients who smoke and nonsmokers. Conclusion This study has shown a significant decrease in CLZ and norCLZ plasma levels, and an increase in the CLZ-to-norCLZ ratio, in smokers as compared to nonsmokers, due to an increase in the clearance of CLZ and norCLZ by smoking induction of CYP 1A2 and glucuronidation by uridyl glucuronyl transferase enzymes (UGT), mainly UGT 1A4, respectively, as the most probable cause.
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Affiliation(s)
- Roberto Lozano
- Department of Pharmacy, University Clinical Hospital, Zaragoza, Spain
| | - Carina Bona
- Unit for the Rational Use of Medicines, Aragon Health Service, Zaragoza, Spain
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Pisani F, Pisani LR, Barbieri MA, de Leon J, Spina E. Optimization of Therapy in Patients with Epilepsy and Psychiatric Comorbidities: Key Points. Curr Neuropharmacol 2023; 21:1755-1766. [PMID: 35619263 PMCID: PMC10514544 DOI: 10.2174/1570159x20666220526144314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/24/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
Psychiatric disorder comorbidity in patients with epilepsy (PWE) is very frequent with a mean percentage prevalence of up to 50% and even higher. Such a high frequency suggests that epilepsy and psychiatric disorders might share common pathological pathways. Various aspects contribute in making the matter very complex from a therapeutic point of view. Some antiseizure medications (ASMs), namely valproic acid, carbamazepine, and lamotrigine, have mood-stabilising effects and are routinely used for the treatment of bipolar disorder in patients who do not have epilepsy. Pregabalin and, to a lesser extent, gabapentin, exerts anxiolytic effects. However, several ASMs, in particular levetiracetam, topiramate, and perampanel, may contribute to psychiatric disorders, including depression, aggressive behaviour, and even psychosis. If these ASMs are prescribed, the patient should be monitored closely. A careful selection should be made also with psychotropic drugs. Although most of these can be safely used at therapeutic doses, bupropion, some tricyclic antidepressants, maprotiline, and clozapine may alter seizure threshold and facilitate epileptic seizures. Interactions between ASMs and psychotropic medication may make it difficult to predict individual response. Pharmacokinetic interactions can be assessed with drug monitoring and are consequently much better documented than pharmacodynamic interactions. Another aspect that needs a careful evaluation is patient adherence to treatment. Prevalence of non-adherence in PWE and psychiatric comorbidities is reported to reach values even higher than 70%. A careful evaluation of all these aspects contributes in optimizing therapy with a positive impact on seizure control, psychiatric wellbeing, and quality of life.
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Affiliation(s)
- Francesco Pisani
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | | | | | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA and Psychiatry and Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Italy
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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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Torrico TJ. The pathophysiology of rapid fluctuations in mental status associated with olanzapine: A case report. Front Psychiatry 2022; 13:1028350. [PMID: 37082516 PMCID: PMC10111197 DOI: 10.3389/fpsyt.2022.1028350] [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: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 12/02/2022] Open
Abstract
BackgroundOlanzapine toxicity is reported to be a rare but specific phenomenon characterized by rapid fluctuations between somnolence and agitation, which has been referred to as “agitation despite sedation.” A similar phenomenon is observed as an adverse reaction of the long-acting injectable olanzapine formulation, which has been referred to as “delirium/sedation syndrome.”Case presentationThis case report describes a 48-year-old man diagnosed with schizophrenia who experienced rapid fluctuations between somnolence and agitation during a cross-titration of olanzapine to clozapine. The patient had normal serum levels of both medications and the symptoms resolved with the discontinuation of olanzapine.ConclusionRapid fluctuations in mental status between somnolence and agitation are not clearly described among other antipsychotics, and it is possible that this phenomenon may be specific to olanzapine. The findings of this case report suggested that this phenomenon was likely the result of the oversaturation of (H1) and (M1) receptors.
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Affiliation(s)
- Tyler J. Torrico
- Department of Psychiatry, Kern Medical, Bakersfield, CA, United States
- American Psychiatric Association Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellowship, Washington, DC, United States
- *Correspondence: Tyler J. Torrico,
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14
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Yadav DS. Clozapine and seizure risk: primary or secondary prophylaxis? PROGRESS IN NEUROLOGY AND PSYCHIATRY 2022. [DOI: 10.1002/pnp.768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Devender Singh Yadav
- Dr Yadav is Associate Specialist in Psychiatry and Responsible Clinician at Heatherwood Court Hospital, Pontypridd
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15
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Correll CU, Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Seppälä N, Howes OD. A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia. CNS Drugs 2022; 36:659-679. [PMID: 35759211 PMCID: PMC9243911 DOI: 10.1007/s40263-022-00932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.
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Affiliation(s)
- C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea de Bartolomeis
- Section on Clinical Psychiatry and Psychology, Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, University of Naples Federico II, Naples, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Niko Seppälä
- Department of Psychiatry Satasairaala, Harjavalta, Finland
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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16
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Sangüesa E, Cirujeda C, Concha J, Padilla PP, García CB, Ribate MP. Exploring the usefulness of plasma level determination and pharmacogenetics for patients treated with clozapine. Per Med 2022; 19:181-192. [PMID: 35259926 DOI: 10.2217/pme-2021-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aims: The aims of the present study were to assess the variance of plasma clozapine (CLZ) levels and to identify the influence of sociodemographic and pharmacogenetic factors on it and to introduce these tools in a clinical setting. Patients & methods: CLZ concentration was measured and genetic variants of CLZ pharmacokinetic and pharmacodynamic factors were assessed in 23 patients with psychotic disorders. Results: A significant association between mean concentration/dose ratio (C/D) and smoking status, age and weight were found. There was a significant difference in mean plasma CLZ levels and gender. The rs762551 AA genotype in smokers had a significantly lower C/D. Conclusion: In addition to classical factors, monitoring of plasma concentrations together with pharmacogenetics led to greater individualization of treatment.
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Affiliation(s)
- Estela Sangüesa
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Christine Cirujeda
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Julia Concha
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Pedro Pablo Padilla
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Cristina Belén García
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - María Pilar Ribate
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
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17
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Diffusion- and Chemometric-Based Separation of Complex Electrochemical Signals That Originated from Multiple Redox-Active Molecules. Polymers (Basel) 2022; 14:polym14040717. [PMID: 35215630 PMCID: PMC8875081 DOI: 10.3390/polym14040717] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 02/05/2023] Open
Abstract
In situ analysis of multiple biomarkers in the body provides better diagnosis and enables personalized health management. Since many of these biomarkers are redox-active, electrochemical sensors have shown promising analytical capabilities to measure multiple redox-active molecules. However, the analytical performance of electrochemical sensors rapidly decreases in the presence of multicomponent biofluids due to their limited ability to separate overlapping electrochemical signals generated by multiple molecules. Here we report a novel approach to use charged chitosan-modified electrodes to alter the diffusion of ascorbic acid, clozapine, L-homocysteine, and uric acid—test molecules with various molecular charges and molecular weights. Moreover, we present a complementary approach to use chemometrics to decipher the complex set of overlapping signals generated from a mixture of differentially charged redox molecules. The partial least square regression model predicted three out of four redox-active molecules with root mean square error, Pearson correlation coefficient, and R-squared values of 125 µM, 0.947, and 0.894; 51.8 µM, 0.877, and 0.753; 55.7 µM, 0.903, and 0.809, respectively. By further enhancing our understanding of the diffusion of redox-active molecules in chitosan, the in-situ separation of multiple molecules can be enabled, which will be used to establish guidelines for the effective separation of biomarkers.
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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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19
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Combining Therapeutic Drug Monitoring and Pharmacokinetic Modelling Deconvolutes Physiological and Environmental Sources of Variability in Clozapine Exposure. Pharmaceutics 2021; 14:pharmaceutics14010047. [PMID: 35056943 PMCID: PMC8779032 DOI: 10.3390/pharmaceutics14010047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Clozapine is a key antipsychotic drug for treatment-resistant schizophrenia but exhibits highly variable pharmacokinetics and a propensity for serious adverse effects. Currently, these challenges are addressed using therapeutic drug monitoring (TDM). This study primarily sought to (i) verify the importance of covariates identified in a prior clozapine population pharmacokinetic (popPK) model in the absence of environmental covariates using physiologically based pharmacokinetic (PBPK) modelling, and then to (ii) evaluate the performance of the popPK model as an adjunct or alternative to TDM-guided dosing in an active TDM population. Methods: A popPK model incorporating age, metabolic activity, sex, smoking status and weight was applied to predict clozapine trough concentrations (Cmin) in a PBPK-simulated population and an active TDM population comprising 142 patients dosed to steady state at Flinders Medical Centre in Adelaide, South Australia. Post hoc analyses were performed to deconvolute the impact of physiological and environmental covariates in the TDM population. Results: Analysis of PBPK simulations confirmed age, cytochrome P450 1A2 activity, sex and weight as physiological covariates associated with variability in clozapine Cmin (R2 = 0.7698; p = 0.0002). Prediction of clozapine Cmin using a popPK model based on these covariates accounted for <5% of inter-individual variability in the TDM population. Post hoc analyses confirmed that environmental covariates accounted for a greater proportion of the variability in clozapine Cmin in the TDM population. Conclusions: Variability in clozapine exposure was primarily driven by environmental covariates in an active TDM population. Pharmacokinetic modelling can be used as an adjunct to TDM to deconvolute sources of variability in clozapine exposure.
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20
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Shad MU. Underuse and Suboptimal Use of Clozapine in Treatment-Refractory Schizophrenia. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20211105-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Tsukahara M, So R, Yada Y, Kodama M, Kishi Y. Clinical Utility and Safety of Slower-than-Recommended Titration of Clozapine for Treatment-Resistant Schizophrenia: a Retrospective Cohort Study. Psychiatr Q 2021; 92:703-713. [PMID: 32889690 DOI: 10.1007/s11126-020-09841-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
Slow titration of clozapine is recommended given the risk of serious adverse effects. However, the utility and safety of slower-than-recommended titration of clozapine remain unclear. Consequently, we aimed to investigate the clinical utility and safety of slower-than-recommended titration of clozapine for treatment-resistant schizophrenia. We conducted a retrospective chart review of 152 inpatients with treatment-resistant schizophrenia who had been newly started on clozapine in a tertiary psychiatric public hospital between April 2012 and March 2018. The primary outcome was clozapine continuation for the first 18 weeks. We performed multivariate logistic regression to identify the association between the rate of clozapine dose titration and clozapine continuation for the first 18 weeks. Among the 152 inpatients, 122 (80%) could continue clozapine for the first 18 weeks. There was no significant association between the rate of clozapine dose titration and clozapine continuation for the first 18 weeks (adjusted odds ratio 1.23; 95% CI 0.29-5.26; p = 0.78). Our findings indicate that slower-than-recommended titration of clozapine may not improve toward clozapine continuation for the first 18 weeks. Therefore, it may not be a beneficial option in terms of safe clozapine continuation when starting clozapine for treatment-resistant schizophrenia.
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Affiliation(s)
- Masaru Tsukahara
- Department of Psychiatry, Okayama Psychiatric Medical Center, 3-16 Shikatahon-machi, Kita-ku, Okayama, 700-0915, Japan
| | - Ryuhei So
- Department of Psychiatry, Okayama Psychiatric Medical Center, 3-16 Shikatahon-machi, Kita-ku, Okayama, 700-0915, Japan.
| | - Yuji Yada
- Department of Psychiatry, Okayama Psychiatric Medical Center, 3-16 Shikatahon-machi, Kita-ku, Okayama, 700-0915, Japan
| | - Masafumi Kodama
- Department of Psychiatry, Okayama Psychiatric Medical Center, 3-16 Shikatahon-machi, Kita-ku, Okayama, 700-0915, Japan
| | - Yoshiki Kishi
- Department of Psychiatry, Okayama Psychiatric Medical Center, 3-16 Shikatahon-machi, Kita-ku, Okayama, 700-0915, Japan
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22
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Lee J, Kim MG, Jeong HC, Shin KH. Physiologically-based pharmacokinetic model for clozapine in Korean patients with schizophrenia. Transl Clin Pharmacol 2021; 29:33-44. [PMID: 33854999 PMCID: PMC8020364 DOI: 10.12793/tcp.2021.29.e3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 12/18/2022] Open
Abstract
Clozapine has been used as a treatment of schizophrenia. Despite its large interindividual variability, few reports addressed the physiologically-based pharmacokinetic modeling and simulation (PBPK M&S) of clozapine in patients. This study aimed to develop a PBPK M&S of clozapine in Korean patients with schizophrenia. PBPK modeling for clozapine was constructed using a population-based PBPK platform, the SimCYP® Simulator (V19; Certara, Sheffield, UK). The PBPK model was developed by optimizing the physiological parameters of the built-in population and compound libraries in the SimCYP® Simulator. The model verification was performed with the predicted/observed ratio for pharmacokinetic parameters and visual predictive checks (VPCs) plot. Simulations were performed to predict toxicities according to dosing regimens. From published data, 230 virtual trials were simulated for each dosing regimen. The predicted/observed ratio for the area under the curve and peak plasma concentration was calculated to be from 0.78 to 1.34. The observation profiles were within the 5th and 95th percentile range with no serious model misspecification through the VPC plot. A significant impact on age and gender was found for clozapine clearance. The simulation results suggested that 150 mg twice a day and 150 mg three times a day of clozapine have toxicity concerns. In conclusion, a PBPK model was developed and reasonable parameters were made from the data of Korean patients with schizophrenia. The provided model might be used to predict the pharmacokinetics of clozapine and assist dose adjustment in clinical settings.
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Affiliation(s)
- Joomi Lee
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
| | - Min-Gul Kim
- Center for Clinical Pharmacology and Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju 54907, Korea.,Department of Pharmacology, School of Medicine, Jeonbuk National University, Jeonju 54907, Korea
| | - Hyeon-Cheol Jeong
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
| | - Kwang-Hee Shin
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
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23
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Yada Y, Kitagawa K, Sakamoto S, Ozawa A, Nakada A, Kashiwagi H, Okahisa Y, Takao S, Takaki M, Kishi Y, Yamada N. The relationship between plasma clozapine concentration and clinical outcome: a cross-sectional study. Acta Psychiatr Scand 2021; 143:227-237. [PMID: 33274435 DOI: 10.1111/acps.13264] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There is no report that statistically evaluates the therapeutic reference (350-600 ng/ml) and adverse drug reaction (ADR) range (>1000 ng/ml) of clozapine (CLZ) recommended by the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) consensus guidelines in an isolated and large sampling study. METHODS We administered CLZ to 131 Japanese patients with treatment-resistant schizophrenia in a multicenter cross-sectional study. Plasma CLZ concentrations were assayed by high-performance liquid chromatography using trough sampling. The Brief Psychiatric Rating Scale (BPRS) and severe dose-dependent ADR (sedation, myoclonus, and seizures) were analyzed statistically after adjusting for possible confounders. RESULTS The daily CLZ dosage showed a moderately positive relationship with the plasma concentration (r = 0.49, p < 0.001). Every 100 ng/ml increase in plasma CLZ concentration improved the total BPRS score 1.95% (95% CI: 0.89-3.01, p < 0.001) and the odds ratio (OR) 1.38 (95% CI: 1.14-1.66, p = 0.001) for BPRS response. Compared with concentrations below 350 ng/ml CLZ, 350-600 ng/ml (11.12%; 95% CI: 2.52-19.72, p = 0.012) and 600-1000 ng/ml (11.05%; 95% CI: 2.40-19.71, p = 0.013) showed significant improvement in the total BPRS score. Dosages above 1000 ng/ml showed greater improvement (25.36%; 95% CI: 13.08-37.64, p < 0.001) of the total BPRS score but more severe ADRs than dosages below 1000 ng/ml (OR: 31.72; 95% CI: 1.04-968.81, p = 0.048). CONCLUSION The AGNP therapeutic reference range (350-600 ng/ml) is useful, and a dose above 1000 ng/ml is potentially more effective but carries the risk of severe ADRs in the central nervous system.
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Affiliation(s)
- Yuji Yada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Okayama Psychiatric Medical Center, Okayama, Japan
| | | | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | | | - Hiroko Kashiwagi
- Department of Forensic Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuko Okahisa
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Soshi Takao
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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John AP, Kecanovic A. Unusually high serum levels of clozapine associated with genetic polymorphism of CYP3A enzymes. Asian J Psychiatr 2021; 57:102126. [PMID: 32386926 DOI: 10.1016/j.ajp.2020.102126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 12/01/2022]
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Clozapine intoxication with severe adverse effects induced by an inflammatory and infectious process: a case report. J Med Case Rep 2021; 15:47. [PMID: 33550992 PMCID: PMC7869193 DOI: 10.1186/s13256-020-02660-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022] Open
Abstract
Background Clozapine intoxication can be life-threatening. Outside of the common drug–drug interactions, tobacco smoking, and caffeine consumption, infectious and inflammatory processes are important contributors to clozapine intoxication. Although this relationship has been reported previously, the literature is scant of proper research articles describing the presentation and management of this unpredictable interaction. Therefore, clinicians need to rely heavily on case reports describing clozapine intoxication caused by inflammation and/or infection. Case presentation A 64-year-old Caucasian woman known for schizophrenia was brought to the emergency department (ED) with severe signs and symptoms of clozapine intoxication (general deterioration, drowsiness, neutropenia, and ileus). She was on clozapine 700 mg daily amongst other medications. The clozapine dose was stable for over 3 years, and there were no recent changes in her medications. The initial culprit was determined to be an infectious/inflammatory process of gastrointestinal origin with contribution from dehydration and constipation. Clozapine and norclozapine serum concentrations confirmed the intoxication: 1315 ng/mL and 653 ng/mL, respectively. She drastically improved with clozapine dose reduction and antibiotic therapy. She remained stable for years with clozapine 600 mg daily with stable clozapine serum levels. Conclusion This case report illustrates the possibility of severe toxicity associated with an acute infectious and/or inflammatory process in patients on clozapine therapy. Clinicians must maintain a high level of suspicion in patients taking clozapine who develop and an infectious and/or inflammatory process. Constipation secondary to clozapine intoxication can exacerbate the initial intoxication process.
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Senel M, Alachkar A. Lab-in-a-pencil graphite: A 3D-printed microfluidic sensing platform for real-time measurement of antipsychotic clozapine level. LAB ON A CHIP 2021; 21:405-411. [PMID: 33331378 DOI: 10.1039/d0lc00970a] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A novel lab-in-a-pencil graphite microfluidic sensing electrode (μFSE) was fabricated for real-time flow injection measurement of the antipsychotic drug clozapine (Clz). A simple, low-cost, and reusable μFSE was obtained by using 3D printing of a microfluidic chamber integrated with a flat pencil graphite without the need to utilize complex technologies. The μFSE has tubular geometry with 800 μm diameter, where the solution continuously flows in the holes of flat pencil graphite electrodes. Under optimized conditions, this device offers fast and effective Clz detection with good analytical features. A linear calibration curve in the range of 0.5 to 10 μM Clz was obtained with good sensitivity (0.01275 μA μM-1) and detection limit (24 nM). Finally, we demonstrate the applicability of our lab-fabricated microfluidic electrochemical device by monitoring Clz in serum samples at low concentrations.
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Affiliation(s)
- Mehmet Senel
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, CA 92697-4625, USA.
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27
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Yoshida K, Takeuchi H. Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia. Behav Brain Res 2021; 402:113098. [PMID: 33417992 DOI: 10.1016/j.bbr.2020.113098] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/02/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antipsychotics are a cornerstone of pharmacological treatment of schizophrenia. Improved understanding of the dose-response relationship of antipsychotics in terms of efficacy, adverse effects, and mortality can help to optimize the pharmacological treatment of schizophrenia. METHODS This narrative literature review summarizes current evidence on the relationship of antipsychotic dose with efficacy, adverse effects, and mortality in patients with schizophrenia. RESULTS The efficacy of antipsychotics generally appeared to be highly dose-dependent in the acute phase of schizophrenia, with each antipsychotic having a specific dose-response curve. The presence or absence of dose-dependency and its extent varied according to the type of adverse effect. Parkinsonism, hyperprolactinemia, weight gain, and neurocognitive impairment appeared to be dose-related. The following adverse effects might be at least somewhat dose-dependent: akathisia, tardive dyskinesia, osteoporosis, sexual dysfunction, diabetes mellitus, myocardial infarction, stroke, thromboembolism, QT interval prolongation, anticholinergic adverse effects, somnolence, pneumonia, hip fracture, and neuroleptic malignant syndrome. In contrast, the relationships of antipsychotic dose with dyslipidemia, hypotension, seizure, sialorrhea, and neutropenia and agranulocytosis remained unclear due to mixed findings and/or limited data. Although a higher lifetime cumulative antipsychotic dose might contribute to higher mortality, it is still difficult to conclude whether mortality increases in a dose-dependent manner. CONCLUSION These findings could help clinicians to optimize antipsychotic treatment in patients with schizophrenia by balancing risks and benefits in clinical practice. However, further investigations with larger sample sizes and more robust study designs that focus on each antipsychotic agent are needed.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Krivoy A, Whiskey E, Webb-Wilson H, Joyce D, Tracy DK, Gaughran F, MacCabe JH, Shergill SS. Outcomes in treatment-resistant schizophrenia: symptoms, function and clozapine plasma concentrations. Ther Adv Psychopharmacol 2021; 11:20451253211037179. [PMID: 34676067 PMCID: PMC8524694 DOI: 10.1177/20451253211037179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine is the only medication licenced for treating patients with treatment-refractory schizophrenia. However, there are no evidence-based guidelines as to the optimal plasma level of clozapine to aim for, and their association with clinical and functional outcome. OBJECTIVE We assessed the relationship between clinical and functional outcome measures and blood concentrations of clozapine among patients with treatment-refractory psychosis. METHODS Data were reviewed in 82 patients with treatment-refractory psychosis admitted to a specialised tertiary-level service and treated with clozapine. Analysis focussed on the relationship between clozapine and norclozapine plasma concentrations and the patient's clinical symptoms and functional status. RESULTS Clinical symptom improvement was positively correlated with norclozapine plasma concentrations and inversely correlated with clozapine to norclozapine plasma concentrations ratio. Clozapine concentrations showed a bimodal association with clinical improvement (peaks around 350 and 660 ng/ml). Clinical symptom improvement correlated with functional outcomes, although there was no significant correlation between the latter and clozapine or norclozapine plasma concentrations. CONCLUSION Clozapine treatment was associated with optimal clinical improvement at two different peak plasma concentrations around 350 and 650 ng/ml. Clinical improvement was associated with functional outcome; however, functionality was not directly associated with clozapine concentrations. A subset of patients may require higher clozapine plasma concentrations to achieve clinical improvement.
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Affiliation(s)
- Amir Krivoy
- Geha Mental Health Center, Petach-Tikva, Israel
| | - Eromona Whiskey
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Henrietta Webb-Wilson
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Dan Joyce
- National Institute of Health Research Oxford Health Biomedical Research Center and Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Derek K Tracy
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - James H MacCabe
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhwinder S Shergill
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
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Proença P, Monteiro C, Mustra C, Claro A, Franco J, Corte-Real F. Identification and Quantification of Antipsychotics in Blood Samples by LC-MS-MS: Case Reports and Data from Three Years of Routine Analysis. J Anal Toxicol 2020; 44:915-922. [PMID: 32780823 DOI: 10.1093/jat/bkaa100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/21/2020] [Accepted: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
Antipsychotic drugs (AP) are widely prescribed for the treatment of schizophrenia and psychosis. The pharmacological treatment of schizophrenia is often performed with the simultaneous use of two or more antipsychotic agents to achieve the desired control of psychotic symptoms Available AP include both conventional (typical) and new (atypical) antipsychotic medications. Atypical AP, such as quetiapine, now account for the vast majority of AP prescriptions. In forensic toxicology, AP are of considerable interest because of their potential abuse and their involvement in intoxications and suicides. The authors retrospectively examined AP positive cases detected in samples collected during autopsies performed in the Forensic Clinical and Pathology Service of National Institute of Legal Medicine and Forensic Sciences Centre Branch or in other autopsies carried out in the central region of Portugal, between January 2016 and December 2018. A quantitative liquid chromatography-tandem mass spectrometry assay was developed for the simultaneous determination of 16 AP (amisulpride, aripiprazole, chlorpromazine, clozapine, cyamemazine, fluphenazine, haloperidol, levomepromazine, melperone, olanzapine, paliperidone, promethazine, quetiapine, risperidone, sulpiride and ziprasidone) in blood samples of postmortem cases. The Laboratory of Forensic Chemistry and Toxicology received 3,588 requests for toxicological analysis: 1,413 cases were positive for drugs from which 351 (24.8%) cases were positive for AP, 60.1% from male individuals and 39.9% from female. Quetiapine was the most prevalent AP (36.5%) followed by olanzapine (20.8%). During this period, there were 25 postmortem cases with AP blood concentrations above therapeutic range, in which 36% of those are in agreement with the information received (psychological history or acute intoxication suspicion) and the manner of death was suicide. Our results point that antipsychotics are an increasingly prevalent class of drugs. AP must be measured not only in toxic concentrations but also in therapeutic levels in postmortem cases; therefore, it is important to come up with a sensitive method to cover the low therapeutic range in which AP are usually present.
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Affiliation(s)
- Paula Proença
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Centro, Coimbra, Portugal
| | - Carla Monteiro
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Centro, Coimbra, Portugal
| | - Carla Mustra
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Centro, Coimbra, Portugal
| | - Alda Claro
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Centro, Coimbra, Portugal
| | - João Franco
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Sul, Lisboa, Portugal
| | - Francisco Corte-Real
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P., Delegação do Centro, Coimbra, Portugal.,Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
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30
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Zhang Y, Qiu S, Orlova E. The systemic inflammatory response syndrome in acute antipsychotic poisoning. J Biochem Mol Toxicol 2020; 34:e22546. [PMID: 32583942 DOI: 10.1002/jbt.22546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/06/2020] [Accepted: 06/05/2020] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to investigate the mutual effect of systemic inflammatory response syndrome (SIRS) accompanied with fibrinolysis, endotoxemia, and coagulation in severe cases of antipsychotic poisoning. A total of 199 patients were examined, of which 71 were men and 128 were women. The age of the patients was from 22 to 63 years, (45.3 ± 6.1 years on average). According to the results of the course of therapy, the patients were divided into two groups. In the blood plasma, the content of C-reactive protein, fibrinogen and its proteolysis products (oligopeptides, D-dimers), interleukin-6 were determined. In the first 1 to 3 days, in group 1, the level of interleukin-6 decreased and approached the normal level (P ≤ .05). The opposite trend continued throughout the observation of patients from group 2-their levels of interleukin-6 increased day by day (P ≤ .05). The concentration of D-dimer already in 1 day after admission to intensive care in patients from group 2 exceeded the norm by 14 times (P ≤ .05). The level of D-dimer correlated with the level of oligopeptides in blood plasma upon admission, as well as for 3 and 5 days after admission to intensive care: 0.36, 0.76 at P ≤ .05, 0.94 at P ≤ .01, respectively. Similar correlations were obtained for the content of oligopeptides in urine and the level of D-dimer: 0.55, 0.85 at P ≤ .05, 0.93 at P ≤ .01. In this regard, the most pronounced correlation is that between the SIRS score, plasma D-dimer level, and the plasma level of the D-dimer derivatives, oligopeptides.
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Affiliation(s)
- Yaqun Zhang
- Tomsk State University, Tomsk, Russian Federation
- Shenyang Normal University, Shenyang, China
| | - Shengnu Qiu
- University College London, London, United Kingdom
| | - Ekaterina Orlova
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
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31
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Elmorsy E, Alelwani W, Kattan S, Babteen N, Alnajeebi A, Ghulam J, Mosad S. Antipsychotics inhibit the mitochondrial bioenergetics of pancreatic beta cells isolated from CD1 mice. Basic Clin Pharmacol Toxicol 2020; 128:154-168. [PMID: 32860481 DOI: 10.1111/bcpt.13484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 01/14/2023]
Abstract
Antipsychotics (APs) are widely used medications with reported diabetogenic side effects. This study investigated the effect of commonly used APs, namely chlorpromazine (CPZ), haloperidol (HAL) and clozapine, on the bioenergetics of male CD1 mice isolated pancreatic beta cells as an underlying mechanism of their diabetogenic effects. The effect of APs on Alamar blue reduction, adenosine triphosphate (ATP) production and glucose-stimulated insulin secretion (GSIS) of isolated beta cells was evaluated. Then, the effects of APs on the activities of mitochondrial complexes and their common coding genes expression, oxygen consumption rate (OCR), mitochondrial membrane potential (MMP) and lactate production were investigated. The effects of APs on the mitochondrial membrane fluidity (MMF) and mitochondrial membrane fatty acid composition were also examined. Results showed that the tested APs significantly decreased cellular ATP production and GSIS of the beta cells. The APs significantly inhibited the activities of mitochondrial complexes and their coding gene expression, MMP and OCR of the treated cells, with a parallel increase in lactate production to different extents with the different APs. CPZ and HAL showed increased MMF and mitochondrial membrane polyunsaturated fatty acid content. In conclusion, the tested APs-induced mitochondrial disruption can play a role in their diabetogenic side effect.
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Affiliation(s)
- Ekramy Elmorsy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Pathology Department, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
| | - Walla Alelwani
- Department of Biochemistry, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Shahad Kattan
- Medical Laboratory Department, College of Applied Medical Sciences, Taibah University, Yanbu, Saudi Arabia
| | - Nouf Babteen
- Department of Biochemistry, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Afnan Alnajeebi
- Department of Biochemistry, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Jihan Ghulam
- General Education Department, Dar Al-Hekma University, Jeddah, Saudi Arabia
| | - Soad Mosad
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Pathology Department, Faculty of Medicine, King Khalid University, Abha, Saudi Arabia
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32
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Comparison of Novel Immunoassay With Liquid Chromatography/Tandem Mass Spectrometry (LC-MS/MS) for Therapeutic Drug Monitoring of Clozapine. Ther Drug Monit 2020; 42:771-777. [DOI: 10.1097/ftd.0000000000000777] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Shukla RP, Cazelles R, Kelly DL, Ben-Yoav H. A reduced-graphene oxide-modified microelectrode for a repeatable detection of antipsychotic clozapine using microliters-volumes of whole blood. Talanta 2020; 209:120560. [DOI: 10.1016/j.talanta.2019.120560] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 12/16/2022]
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34
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Jovanović M, Vučićević K, Miljković B. Understanding variability in the pharmacokinetics of atypical antipsychotics - focus on clozapine, olanzapine and aripiprazole population models. Drug Metab Rev 2020; 52:1-18. [PMID: 32008418 DOI: 10.1080/03602532.2020.1717517] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Antipsychotic medicines are widely used for the management of psychotic symptoms regardless of the underlying diagnosis. Most atypical antipsychotics undergo extensive metabolism prior to excretion. Various factors may influence their pharmacokinetics, particularly elimination, leading to highly variable drug concentrations between individual patients following the same dosing regimen. Population pharmacokinetic approach, based on nonlinear mixed effects modeling, is a useful tool to identify covariates explaining pharmacokinetic variability, as well as to characterize and distinguish unexplained residual and between-subject (interindividual) variability. In addition, this approach allows the use of both sparsely and intensively sampled data. In this paper, we reviewed the pharmacokinetic characteristics of clozapine, olanzapine and aripiprazole, focusing on a population modeling approach. In particular, models based on a nonlinear mixed effects approach performed by NONMEM® software in order to identify and quantify sources of pharmacokinetic variability are presented. Population models were identified through systematic searches of PubMed and sixteen studies were selected. Some of the factors identified that significantly contribute to variability in elimination among clozapine, olanzapine, and aripiprazole are demographic characteristics, body weight, genetic polymorphism, smoking and in some cases drug interactions. Scientific research based on pharmacometric modeling is useful to further characterize sources of variability and their combined effect.
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Affiliation(s)
- Marija Jovanović
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Belgrade, Republic of Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Belgrade, Republic of Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Belgrade, Republic of Serbia
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35
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Gisi C, Munteanu A, Ku L, French S, Fleischman M, Eysselein V. Atypical Presentation of Acquired Hypoganglionosis in a Patient Taking Clozapine. Case Rep Gastrointest Med 2020; 2020:1272567. [PMID: 32670642 PMCID: PMC7333039 DOI: 10.1155/2020/1272567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 01/22/2023] Open
Abstract
Acquired hypoganglionosis (HG) is a rare enteric gastrointestinal neuromuscular disorder previously associated with chronic inflammation that can lead to constipation, ileus, and even death. There is little known about the pathophysiology of acquired hypoganglionosis, and it is unclear if medications are related to the development of the disease. Clozapine is an atypical antipsychotic used to treat refractory schizophrenia that is well known for its side effects including agranulocytosis and gastrointestinal dysmotility. This is an unusual case of acquired hypoganglionosis in a patient with anticholinergic toxicity on clozapine therapy.
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Affiliation(s)
- Catherine Gisi
- 1Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Anamaria Munteanu
- 2Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Lawrence Ku
- 1Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Samuel French
- 2Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Michael Fleischman
- 3Department of Internal Medicine, Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Viktor Eysselein
- 3Department of Internal Medicine, Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA, USA
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36
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Shukla RP, Ben‐Yoav H. A Chitosan-Carbon Nanotube-Modified Microelectrode for In Situ Detection of Blood Levels of the Antipsychotic Clozapine in a Finger-Pricked Sample Volume. Adv Healthc Mater 2019; 8:e1900462. [PMID: 31240866 DOI: 10.1002/adhm.201900462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/07/2019] [Indexed: 01/06/2023]
Abstract
The antipsychotic clozapine is the most effective medication available for schizophrenia and it is the only antipsychotic with a known efficacious clinical range. However, it is dramatically underutilized due to the inability to test clozapine blood levels in finger-pricked patients' samples. This prevents obtaining immediate blood levels information, resulting in suboptimal treatment. The development of an electrochemical microsensor is presented, which enables, for the first time, clozapine detection in microliters volume whole blood. The sensor is based on a microelectrode modified with micrometer-thick biopolymer chitosan encapsulating carbon nanotubes. The developed sensor detects clozapine oxidation current, in the presence of other electroactive species in the blood, which generate overlapping electrochemical signals. Clozapine detection, characterized in whole blood from healthy volunteers, displays a sensitivity of 32 ± 3.0 µA cm-2 µmol-1 L and a limit-of-detection of 0.5 ± 0.03 µmol L-1 . Finally, the developed sensor displays a reproducible electrochemical signal (0.6% relative standard deviation) and high storage stability (9.8% relative standard deviation after 8 days) in serum samples and high repeatability (9% relative standard deviation for the 5th repetition) in whole blood samples. By enabling the rapid and minimally invasive clozapine detection at the point-of-care, an optimal schizophrenia treatment is provided.
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Affiliation(s)
- Rajendra P. Shukla
- Nanobioelectronics LaboratoryDepartment of Biomedical EngineeringBen‐Gurion University of the Negev Beer‐Sheva 8410501 Israel
| | - Hadar Ben‐Yoav
- Nanobioelectronics LaboratoryDepartment of Biomedical EngineeringBen‐Gurion University of the Negev Beer‐Sheva 8410501 Israel
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37
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Inhibition of Epstein-Barr Virus Lytic Reactivation by the Atypical Antipsychotic Drug Clozapine. Viruses 2019; 11:v11050450. [PMID: 31108875 PMCID: PMC6563273 DOI: 10.3390/v11050450] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
Epstein–Barr virus (EBV), a member of the Herpesviridae family, maintains a lifelong latent infection in human B cells. Switching from the latent to the lytic phase of its lifecycle allows the virus to replicate and spread. The viral lytic cycle is induced in infected cultured cells by drugs such as sodium butyrate and azacytidine. Lytic reactivation can be inhibited by natural products and pharmaceuticals. The anticonvulsant drugs valproic acid and valpromide inhibit EBV in Burkitt lymphoma cells. Therefore, other drugs that treat neurological and psychological disorders were investigated for effects on EBV lytic reactivation. Clozapine, an atypical antipsychotic drug used to treat schizophrenia and bipolar disorder, was found to inhibit the reactivation of the EBV lytic cycle. Levels of the viral lytic genes BZLF1, BRLF1, and BMLF1 were decreased by treatment with clozapine in induced Burkitt lymphoma cells. The effects on viral gene expression were dependent on the dose of clozapine, yet cells were viable at an inhibitory concentration of clozapine. One metabolite of clozapine—desmethylclozapine—also inhibited EBV lytic reactivation, while another metabolite—clozapine-N-oxide—had no effect. These drugs may be used to study cellular pathways that control the viral lytic switch in order to develop treatments for diseases caused by EBV.
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38
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Asenjo-Lobos C, Cortés-Jofré M, Fonseca C, Leucht S, Madrid E, Bonfill Cosp X. Clozapine versus risperidone for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Eva Madrid
- School of Medicine Universidad de Valparaiso. - Cochrane Centre; Interdisciplinary Centre for Health Studies CIESAL; Universidad de Valparaiso Chile
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret 167 Pavilion 18 Barcelona Catalunya Spain 08025
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39
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Asenjo-Lobos C, Fonseca C, Leucht S, Garcia-Ribera C, Cortés-Jofré M. Clozapine versus quetiapine for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Carles Garcia-Ribera
- Hospital de la Santa Creu i Sant Pau; Psychiatry Department; Calle de Sant Quinti, 89 Barcelona Spain 08026
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
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40
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Asenjo-Lobos C, Fonseca C, Leucht S, Arancibia M, Cortés-Jofré M. Clozapine versus olanzapine for people with schizophrenia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Claudia Asenjo-Lobos
- University of Concepción; Concepción Chile
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
| | - Carolina Fonseca
- Universidad de Santiago de Chile; Facultad de Medicina; Santiago de Chile Chile
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der Isar; Klinik und Poliklinik für Psychiatrie und Psychotherapie; München Germany 81675
| | - Marcelo Arancibia
- Universidad de Valparaíso; Interdisciplinary Centre for Health Studies CIESAL; Viña del Mar Chile
| | - Marcela Cortés-Jofré
- Universitat Autònoma de Barcelona; Methodology of Biomedical Research and Public Health; Barcelona Spain
- Universidad Católica de la SS; Facultad de Medicina; Concepción Concepción Chile
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41
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Zhu Q, Yu X, Wu Z, Lu F, Yuan Y. Antipsychotic drug poisoning monitoring of clozapine in urine by using coffee ring effect based surface-enhanced Raman spectroscopy. Anal Chim Acta 2018. [PMID: 29523253 DOI: 10.1016/j.aca.2018.02.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antipsychotics are the drugs most often involved in drug poisoning cases, and therefore, therapeutic drug monitoring (TDM) is necessary for safe and effective medication administration of these drugs. In this study, a coffee ring effect-based surface-enhanced Raman spectroscopy (CRE-SERS) method was developed and successfully used to monitor antipsychotic poisoning by using urine samples for the first time. The established method exhibited excellent SERS performance since more hot spots were obtained in the "coffee ring". Using the optimized CRE-SERS method, the sensitivity was improved one order more than that of the conventional method with reasonable reproducibility. The antipsychotic drug clozapine (CLO) spiked into urine samples at 0.5-50 μg mL-1 was quantitatively detected, at concentrations above the thresholds for toxicity. The CRE-SERS method allowed CLO and its metabolites to be ultimately distinguished from real poisoning urine samples. The coffee-ring effect would provide more opportunities for practical applications of the SERS-based method. The frequent occurrence of drug poisoning may have created a new area for the application of the CRE-SERS method. It is anticipated that the developed method will also have great potential for other drug poisoning monitoring.
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Affiliation(s)
- Qingxia Zhu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Xiaoyan Yu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Zebing Wu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Feng Lu
- Department of Pharmaceutical Analysis, School of Pharmacy, Second Military Medical University, Shanghai, 200433, China
| | - Yongfang Yuan
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China.
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42
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Clark SR, Warren NS, Kim G, Jankowiak D, Schubert KO, Kisely S, Forrester T, Baune BT, Siskind DJ. Elevated clozapine levels associated with infection: A systematic review. Schizophr Res 2018; 192:50-56. [PMID: 28392207 DOI: 10.1016/j.schres.2017.03.045] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 11/27/2022]
Abstract
Clozapine is the most effective anti-psychotic medication for treatment refractory schizophrenia. A growing number of case reports have linked infection to high clozapine levels and associated adverse outcomes. We present a systematic review of published cases to clarify the relationship between infection and elevated clozapine levels. The case reports were located through PubMed and Embase. In addition, 8 new cases from two Australian states were included. Demographics, psychiatric diagnoses and medical morbidities, medications, clinical symptoms, clozapine levels, inflammatory markers and final clinical outcome were extracted. 40 cases were identified in 23 publications that demonstrated elevated clozapine levels associated with infection. Infections were commonly respiratory in origin. Adverse events, typically sedation, were associated with raised clozapine levels during infection. In many cases the signs of infection such as fever and white blood cell count were reduced. Severe adverse effects were uncommon, with one case each of seizure, myocarditis and neutropenia. The relationship between infection, clozapine levels and adverse events is complex and multi-factorial. Monitoring of clozapine levels is essential during hospitalisation for infection and consideration should be given to gradual dose reduction to minimise dose related side effects.
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Affiliation(s)
- Scott R Clark
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - Nicola S Warren
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia.
| | - Gajin Kim
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - David Jankowiak
- Southern Adelaide Local Health Network, Adelaide, South Australia 5042, Australia
| | - Klaus Oliver Schubert
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia; Northern Adelaide Local Health Network, Adelaide, South Australia 5112, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia
| | - Tori Forrester
- Princess Alexandra Hospital, Brisbane, QLD 4012, Australia
| | - Bernhard T Baune
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - Dan J Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia
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Murphy K, Coombes I, Moudgil V, Patterson S, Wheeler A. Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements. J Eval Clin Pract 2017; 23:1164-1172. [PMID: 28471043 DOI: 10.1111/jep.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVE The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme. METHODS This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand). RESULTS Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records. CONCLUSIONS Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.
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Affiliation(s)
- Kate Murphy
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Ian Coombes
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Vikas Moudgil
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Susan Patterson
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Amanda Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
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Kar N, Barreto S, Chandavarkar R. Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2016; 14:323-329. [PMID: 27776383 PMCID: PMC5083942 DOI: 10.9758/cpn.2016.14.4.323] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/20/2016] [Accepted: 02/21/2016] [Indexed: 01/16/2023]
Abstract
Clozapine is effective in treatment resistant schizophrenia; however, it is underutilised probably because of its side effects. The side effects are also the potential reasons for clozapine discontinuation. A mandatory requirement for its use is regular monitoring of white blood cell count and absolute neutrophil count. However there are many side effects that need monitoring in clinical practice considering their seriousness. This article tries to summarise the clinical concerns surrounding the serious side effects of clozapine some of which are associated with fatalities and presents a comprehensive way to monitor patients on clozapine in clinical practice. It emphasizes the need to broaden the monitoring beyond the mandatory investigations. This may help in improving the safety in clinical practice and increasing clinician confidence for greater and appropriate use of this effective intervention.
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Affiliation(s)
- Nilamadhab Kar
- Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom
| | - Socorro Barreto
- Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom
| | - Rahul Chandavarkar
- North Staffordshire Combined Healthcare NHS Trust, Stoke-on-Trent, United Kingdom
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Leung JG, Hasassri ME, Barreto JN, Nelson S, Morgan RJ. Characterization of Admission Types in Medically Hospitalized Patients Prescribed Clozapine. PSYCHOSOMATICS 2016; 58:164-172. [PMID: 28153339 DOI: 10.1016/j.psym.2016.11.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clozapine is the antipsychotic of choice for treatment-resistant schizophrenia; however, rigorous monitoring is required to prevent or detect adverse drug events that contribute to morbidity and mortality. In addition to the Food and Drug Administration (FDA) boxed safety warnings specific to clozapine (agranulocytosis, hypotension, seizures, and cardiomyopathy/myocarditis), other adverse events such as pneumonia and gastrointestinal hypomotility have been reported in the literature to result in hospitalization. OBJECTIVE To explore the reasons for medical hospitalization in patients prescribed clozapine, a retrospective chart review was completed. METHODS Adults with schizophrenia or schizoaffective disorder prescribed clozapine were identified if they had a nonpsychiatric medical admission between 1/1/2003 and 8/1/2015. Demographics, admitting diagnosis, admitting service type, psychiatric consult information, clozapine dosing, and drug interactions were collected. RESULTS Overall, 104 patients, representing 248 hospitalizations, were admitted to a medical unit during the study period. The predominant admission types were for the management of either pulmonary (32.2%) or gastrointestinal (19.8%) illnesses. The most common pulmonary diagnosis was pneumonia, accounting for 58% of pulmonary admissions. Further, 61.2% of the gastrointestinal admissions were related to hypomotility, ranging from constipation to death. Clozapine was discontinued owing to neutropenia in 2 patients; however, in both cases concomitant chemotherapy had been given. CONCLUSION In patients prescribed clozapine admitted to nonpsychiatric medical settings, gastrointestinal and pulmonary illnesses were common, but not illnesses related to boxed warnings. Additional research is needed to better assess the causality and true incidence of gastrointestinal or pulmonary events associated with clozapine. Furthermore, clinicians must be prepared to prevent, detect, and manage potentially life-threatening events associated with clozapine.
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Affiliation(s)
| | | | | | - Sarah Nelson
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Robert J Morgan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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Siskind D, McCartney L, Goldschlager R, Kisely S. Clozapine v. first- and second-generation antipsychotics in treatment-refractory schizophrenia: systematic review and meta-analysis. Br J Psychiatry 2016; 209:385-392. [PMID: 27388573 DOI: 10.1192/bjp.bp.115.177261] [Citation(s) in RCA: 342] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/27/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although clozapine is the 'gold standard' for treatment-refractory schizophrenia, meta-analyses of clozapine for this condition are lacking. AIMS We conducted a systematic review and meta-analysis of clozapine treatment for people with treatment-refractory schizophrenia. METHOD We searched the Cochrane Schizophrenia Group's trial register, PubMed and EMBASE and hand-searched key papers for randomised controlled trials of clozapine for treatment-refractory schizophrenia. RESULTS Twenty-one papers with 25 comparisons were included. The number needed to treat was 9. Clozapine was superior for positive symptoms in both the short and long term. In the short term only clozapine was superior for total and negative symptoms, with higher response rates. Both funding source and dosage affected results. Higher baseline psychosis scores predicted better outcomes for clozapine in a meta-regression. CONCLUSIONS Clozapine is superior for treatment-refractory disorder but if there is no response by 6 months medications with lower adverse reactions should be considered.
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Affiliation(s)
- Dan Siskind
- Dan Siskind, MBBS, PhD, Metro South Addiction and Mental Health Services, Brisbane, and University of Queensland School of Medicine, Brisbane; Lara McCartney, MBBS, Royal Melbourne Hospital, Melbourne; Romi Goldschlager, MBBS, St Vincent's Hospital, Melbourne; Steve Kisely, MD, PhD, Metro South Addiction and Mental Health Services, Brisbane, University of Queensland School of Medicine, Brisbane, and Griffith Health Institute, Brisbane, Australia
| | - Lara McCartney
- Dan Siskind, MBBS, PhD, Metro South Addiction and Mental Health Services, Brisbane, and University of Queensland School of Medicine, Brisbane; Lara McCartney, MBBS, Royal Melbourne Hospital, Melbourne; Romi Goldschlager, MBBS, St Vincent's Hospital, Melbourne; Steve Kisely, MD, PhD, Metro South Addiction and Mental Health Services, Brisbane, University of Queensland School of Medicine, Brisbane, and Griffith Health Institute, Brisbane, Australia
| | - Romi Goldschlager
- Dan Siskind, MBBS, PhD, Metro South Addiction and Mental Health Services, Brisbane, and University of Queensland School of Medicine, Brisbane; Lara McCartney, MBBS, Royal Melbourne Hospital, Melbourne; Romi Goldschlager, MBBS, St Vincent's Hospital, Melbourne; Steve Kisely, MD, PhD, Metro South Addiction and Mental Health Services, Brisbane, University of Queensland School of Medicine, Brisbane, and Griffith Health Institute, Brisbane, Australia
| | - Steve Kisely
- Dan Siskind, MBBS, PhD, Metro South Addiction and Mental Health Services, Brisbane, and University of Queensland School of Medicine, Brisbane; Lara McCartney, MBBS, Royal Melbourne Hospital, Melbourne; Romi Goldschlager, MBBS, St Vincent's Hospital, Melbourne; Steve Kisely, MD, PhD, Metro South Addiction and Mental Health Services, Brisbane, University of Queensland School of Medicine, Brisbane, and Griffith Health Institute, Brisbane, Australia
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Ciprofloxacin and Clozapine: A Potentially Fatal but Underappreciated Interaction. Case Rep Psychiatry 2016; 2016:5606098. [PMID: 27872784 PMCID: PMC5107233 DOI: 10.1155/2016/5606098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. Clozapine provides a 50%–60% response rate in refractory schizophrenia but has a narrow therapeutic index and is susceptible to pharmacokinetic interactions, particularly with strong inhibitors or inducers of cytochrome P450 (CYP) 1A2. Case Report. We report the case of a 28-year-old nonsmoking female with intellectual disability who was maintained for 3 years on clozapine 100 mg orally twice daily. The patient was treated for presumptive urinary tract infection with ciprofloxacin 500 mg orally twice daily and two days later collapsed and died despite resuscitation efforts. The postmortem femoral clozapine plasma level was dramatically elevated at 2900 ng/mL, and the cause of death was listed as acute clozapine toxicity. Conclusion. Given the potentially fatal pharmacokinetic interaction between clozapine and ciprofloxacin, clinicians are advised to monitor baseline clozapine levels prior to adding strong CYP450 1A2 inhibitors, reduce the clozapine dose by at least two-thirds if adding a 1A2 inhibitor such as ciprofloxacin, check subsequent steady state clozapine levels, and adjust the clozapine dose to maintain levels close to those obtained at baseline.
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Orsolini L, Tomasetti C, Valchera A, Vecchiotti R, Matarazzo I, Vellante F, Iasevoli F, Buonaguro EF, Fornaro M, Fiengo ALC, Martinotti G, Mazza M, Perna G, Carano A, De Bartolomeis A, Di Giannantonio M, De Berardis D. An update of safety of clinically used atypical antipsychotics. Expert Opin Drug Saf 2016; 15:1329-47. [PMID: 27347638 DOI: 10.1080/14740338.2016.1201475] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The atypical antipsychotic (APs) drugs have become the most widely used agents to treat a variety of psychoses because of their superiority with regard to safety and tolerability profile compared to conventional/'typical' APs. AREAS COVERED We aimed at providing a synthesis of most current evidence about the safety and tolerability profile of the most clinically used atypical APs so far marketed. Qualitative synthesis followed an electronic search made inquiring of the following databases: MEDLINE, Embase, PsycINFO and the Cochrane Library from inception until January 2016, combining free terms and MESH headings for the topics of psychiatric disorders and all atypical APs as following: ((safety OR adverse events OR side effects) AND (aripiprazole OR asenapine OR quetiapine OR olanzapine OR risperidone OR paliperidone OR ziprasidone OR lurasidone OR clozapine OR amisulpride OR iloperidone)). EXPERT OPINION A critical issue in the treatment with atypical APs is represented by their metabolic side effect profile (e.g. weight gain, lipid and glycaemic imbalance, risk of diabetes mellitus and diabetic ketoacidosis) which may limit their use in particular clinical samples. Electrolyte imbalance, ECG abnormalities and cardiovascular adverse effects may recommend a careful baseline and periodic assessments.
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Affiliation(s)
- L Orsolini
- a School of Life and Medical Sciences , University of Hertfordshire , Hatfield , Herts , United Kingdom.,b Villa San Giuseppe Hospital, Hermanas Hospitalarias , Ascoli Piceno , Italy.,c Polyedra Research Group , Teramo , Italy.,d Department of Psychiatry and Neuropsychology , University of Maastricht , Maastricht , The Netherlands
| | - C Tomasetti
- c Polyedra Research Group , Teramo , Italy.,e NHS, Department of Mental Health ASL Teramo , Psychiatric Service of Diagnosis and Treatment, Hospital 'Maria SS dello Splendore,' Giulianova , Italy.,f Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Reproductive and Odontostomatogical Sciences , University of Naples 'Federico II,' Napoli , Italy
| | - A Valchera
- b Villa San Giuseppe Hospital, Hermanas Hospitalarias , Ascoli Piceno , Italy.,c Polyedra Research Group , Teramo , Italy
| | - R Vecchiotti
- b Villa San Giuseppe Hospital, Hermanas Hospitalarias , Ascoli Piceno , Italy.,c Polyedra Research Group , Teramo , Italy.,d Department of Psychiatry and Neuropsychology , University of Maastricht , Maastricht , The Netherlands
| | - I Matarazzo
- g NHS, Department of Mental Health ASL Teramo, Psychiatric Service of Diagnosis and Treatment , Hospital 'G. Mazzini,' Teramo , Italy.,h Department of Neuroscience and Imaging , University 'G. D'Annunzio,' Chieti , Italy
| | - F Vellante
- g NHS, Department of Mental Health ASL Teramo, Psychiatric Service of Diagnosis and Treatment , Hospital 'G. Mazzini,' Teramo , Italy.,h Department of Neuroscience and Imaging , University 'G. D'Annunzio,' Chieti , Italy
| | - F Iasevoli
- c Polyedra Research Group , Teramo , Italy.,f Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Reproductive and Odontostomatogical Sciences , University of Naples 'Federico II,' Napoli , Italy
| | - E F Buonaguro
- c Polyedra Research Group , Teramo , Italy.,f Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Reproductive and Odontostomatogical Sciences , University of Naples 'Federico II,' Napoli , Italy
| | - M Fornaro
- c Polyedra Research Group , Teramo , Italy.,i New York Psychiatric Institute , Columbia University , New York , NY , USA
| | | | - G Martinotti
- h Department of Neuroscience and Imaging , University 'G. D'Annunzio,' Chieti , Italy
| | - M Mazza
- c Polyedra Research Group , Teramo , Italy.,j Department of Life, Health and Environmental Sciences , University of L'Aquila , L'Aquila , Italy
| | - G Perna
- k Department of Clinical Neurosciences , Hermanas Hospitalarias, FoRiPsi, Villa San Benedetto Menni, Albese con Cassano , Como , Italy.,l Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine , University of Miami , Miami , FL , USA
| | - A Carano
- m NHS, Department of Mental Health ASL Ascoli Piceno, Psychiatric Service of Diagnosis and Treatment , Hospital 'Maria SS del Soccorso,' San Benedetto del Tronto , Italy
| | - A De Bartolomeis
- f Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Reproductive and Odontostomatogical Sciences , University of Naples 'Federico II,' Napoli , Italy
| | - M Di Giannantonio
- i New York Psychiatric Institute , Columbia University , New York , NY , USA
| | - D De Berardis
- c Polyedra Research Group , Teramo , Italy.,g NHS, Department of Mental Health ASL Teramo, Psychiatric Service of Diagnosis and Treatment , Hospital 'G. Mazzini,' Teramo , Italy.,h Department of Neuroscience and Imaging , University 'G. D'Annunzio,' Chieti , Italy
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Abstract
The aim of this study is to evaluate the safety and effectiveness of rapid clozapine titration in patients with schizophrenia in hospital settings. We conducted a retrospective two-center cohort study to compare the safety and effectiveness of clozapine with different titration rates in treatment-refractory patients with schizophrenia. In the first center, clozapine was started at 25-50 mg followed by 50-100 mg as needed every 6 h on day 1, followed by increases of 50-100 mg/day. In the second center, titration was slower; clozapine initiated with 12.5-50 mg on day 1 followed by increases of 25-50 mg/day. The number of days between starting of clozapine until discharge was shorter in the rapid titration group (22.4 ± 8.72 vs 27.0 ± 10.5, p = 0.1). Number of days of total hospital stay were significantly shorter in the rapid titration group (29.6 ± 10.6 vs 41.2 ± 14.8, p = 0.002). Hypotension was more common in the rapid titration group and one patient had suspected myocarditis. Rapid clozapine titration appeared safe and effective. The length of stay following initiation of clozapine was shorter in the rapid-titration group, although this was not statistically significant. However starting clozapine earlier together with rapid titration has significantly shortened the length of hospital stay in patients with treatment refractory schizophrenia.
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De Hert M, De Beugher A, Sweers K, Wampers M, Correll CU, Cohen D. Knowledge of Psychiatric Nurses About the Potentially Lethal Side-Effects of Clozapine. Arch Psychiatr Nurs 2016; 30:79-83. [PMID: 26804506 DOI: 10.1016/j.apnu.2015.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/15/2015] [Accepted: 09/15/2015] [Indexed: 11/24/2022]
Abstract
Clozapine is an antipsychotic with superior efficacy in treatment refractory patients, and has unique anti-suicidal properties and a low propensity to cause extrapyramidal side-effects. Despite these advantages, clozapine utilization is low. This can in part be explained by a number of potentially lethal side effects of clozapine. Next to psychiatrists nurses play a crucial role in the long-term management of patients with schizophrenia. It is therefore important that nurses know, inform and monitor patients about the specific side-effects of clozapine. A recent study of psychiatrists published in 2011 has shown that there was a gap in the knowledge about side-effects of clozapine. The knowledge about side-effects of clozapine in nurses has never been studied. This cross-sectional study evaluated the knowledge base regarding the safety of clozapine, and its potential mediators, of psychiatric nurses in 3 psychiatric hospitals in Belgium with a specifically developed questionnaire based on the literature and expert opinion (3 clozapine experts). A total of 85 nurses completed the questionnaire. The mean total score was 6.1 of a potential maximum score of 18. Only 3 of the 18 multiple choice knowledge questions were answered correctly by more than 50% of nurses. Only 24.9% of participants passed the test (>50% correct answers). Nurses working on psychosis units were more likely to pass the test (xx.y% vs yy.z%, p=0.0124). There was a trend that nurses with a lower nursing diploma were more likely to fail the test (p=0.0561). Our study clearly identifies a large gap in the basic knowledge of psychiatric nurses about clozapine and its side-effects. Knowledge could be increased by more emphasis on the topic in nurse's training curricula as well as targeted onsite training. Only 23.5% of participants indicate that there was sufficient information in their basic nursing training.
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Affiliation(s)
- Marc De Hert
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | - Annelien De Beugher
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | - Kim Sweers
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium.
| | - Martien Wampers
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | | | - Dan Cohen
- Department of Epidemiology, University of Groningen, The Netherlands
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