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Oguro S, Echizen K, Sakakibara E, Koshiyama D, Oji T, Miyake T, Kasai K. Clozapine-induced pemphigus successfully treated with methylprednisolone pulse without discontinuation of clozapine: a case report. Psychiatry Clin Neurosci 2023; 77:572-573. [PMID: 37438873 DOI: 10.1111/pcn.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Affiliation(s)
- Saki Oguro
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
- Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kohei Echizen
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Eisuke Sakakibara
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Daisuke Koshiyama
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Tomoatsu Oji
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Tomomi Miyake
- Department of Dermatology, University of Tokyo Hospital, Tokyo, Japan
| | - Kiyoto Kasai
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity induced by clozapine: Case report and brief review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2023; 52:165-170. [PMID: 37460343 DOI: 10.1016/j.rcpeng.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 04/21/2021] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Peru; Universidad Peruana Cayetano Heredia, Lima, Peru
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de Filippis R, Kane JM, Kuzo N, Spina E, De Sarro G, de Leon J, De Fazio P, Schoretsanitis G. Screening the European pharmacovigilance database for reports of clozapine-related DRESS syndrome: 47 novel cases. Eur Neuropsychopharmacol 2022; 60:25-37. [PMID: 35635994 DOI: 10.1016/j.euroneuro.2022.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/12/2022] [Accepted: 04/16/2022] [Indexed: 12/13/2022]
Abstract
Clozapine-related drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare adverse reaction. We aimed to screen a large pharmacovigilance database to identify clozapine-related DRESS cases, even if otherwise reported and provide a clinical overview. We screened spontaneous reports of clozapine-related DRESS syndrome in EudraVigilance database applying the European Registry on Severe Cutaneous Adverse Drug Reactions (RegiSCAR) criteria and scores to identify probable/definite DRESS syndrome cases. Clinical and demographic characteristics of included cases were provided and associations between RegiSCAR scores, and time to develop/recover DRESS were assessed. In a total of 262,146 adverse drug reactions reports for 75,190 clozapine-treated patients, 596 cases fulfilled RegiSCAR criteria; ultimately, 51 cases were rated as probable/definite DRESS according to RegiSCAR scores, of which 4 were previously published as case reports. The mean age of patients was 41.06 years (43.1% females), with 13 patients (25.5%) receiving reported co-medication with other DRESS culprit drugs. Median time between clozapine initiation and DRESS symptoms was 25 days. Clozapine dose was associated with days to develop symptoms (Spearman's ρ 0.40, p = 0.03). Organ involvement was reported in all cases followed by fever (n = 49; 96.1%) and eosinophilia (n = 47; 92.2%). Treatment involved clozapine discontinuation for 37 patients (72.5%), while 3.9% (n = 2) of cases ended fatally. Clozapine rechallenge was undertaken in 25 patients (49.0%). The screening of the EudraVigilance database revealed 47 novel clozapine-related DRESS cases, and only one was originally reported as DRESS. Clozapine-related DRESS may occur with clozapine monotherapy not only during dose titration, but also during maintenance treatment.
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Affiliation(s)
- Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Nazar Kuzo
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | | | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
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4
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de Filippis R, Soldevila-Matías P, Guinart D, De Fazio P, Rubio JM, Kane JM, Schoretsanitis G. Unravelling cases of clozapine-related Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) in patients reported otherwise: A systematic review. J Psychopharmacol 2021; 35:1062-1073. [PMID: 34044659 DOI: 10.1177/02698811211021587] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a drug-induced hypersensitivity reaction. AIMS Aim was to review reports of clozapine-related reactions fulfilling the registry of severe cutaneous adverse reaction (RegiSCAR) criteria for DRESS syndrome reported as such or otherwise, to provide a descriptive overview of demographic patterns, clinical manifestations, and DRESS course and investigate associations between demographic, DRESS parameters, and clinical outcomes. METHODS This review was conducted following preferred reporting items for systematic reviews and meta-analyses guidelines and registered with PROSPERO (registration number CRD42020156385). We searched PubMed/Embase/PsychInfo/Cochrane for reports of clozapine-related reactions meeting RegiSCAR criteria. Associations between RegiSCAR scores and time-to-recovery with demographic/clinical variables were assessed. Demographic/clinical characteristics of patients with versus without reported DRESS were compared using non-parametrical tests. RESULTS We identified 26 reports of 27 patients meeting RegiSCAR criteria. Males (n = 19, 70.4%) and patients with schizophrenia (n = 18, 66.7%) were mainly affected. Twelve patients (44.4%) received clozapine-monotherapy. DRESS symptoms manifested within a month after clozapine initiation (n = 24, 88.9%). Lungs and liver were the most common organs involved (n = 12, 44.4%; n = 11, 40.7%), with a mean time to recovery of 33.75 days. Clozapine rechallenge led to DRESS recurrence in four patients. Death rate was 7.4%. No associations were detected between RegiSCAR criteria or days to recovery with any demographic/clinical variables. No differences between patients with versus without reported DRESS were detected. CONCLUSIONS Clozapine-related DRESS may be rare, but also underreported. Clinicians need to be aware of it even in patients under clozapine-monotherapy or without skin rash.
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Affiliation(s)
- Renato de Filippis
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Pau Soldevila-Matías
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Research Institute of Clinic University Hospital of Valencia (INCLIVA), Valencia, Spain
| | - Daniel Guinart
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Jose M Rubio
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M Kane
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Georgios Schoretsanitis
- Department of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
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Revilla-Zúñiga J, Cornejo-Del Carpio J, Cruzado L. Hepatoxicity Induced by Clozapine: Case Report and Brief Review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 52:S0034-7450(21)00087-1. [PMID: 34167791 DOI: 10.1016/j.rcp.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/22/2020] [Accepted: 04/21/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Antipsychotics are drugs that can produce transient elevations of hepatic enzymes. Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia and there is evidence that it can produce elevations of hepatic transaminases, expression of liver damage in a hepatocellular pattern. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 39-year-old woman with a diagnosis of paranoid schizophrenia attended the emergency department of a general hospital for nausea, vomiting and jaundice that appeared after the initiation of clozapine. There was no clinical improvement during hospitalisation, and death occurred after 44 days. LITERATURE REVIEW Clozapine can increase the liver enzyme levels transiently and asymptomatically; however, there are clinical criteria that recommend the withdrawal of the antipsychotic. CONCLUSIONS This is the third case reported in the literature of a fatal outcome of clozapine-induced hepatotoxicity.
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Affiliation(s)
- Joshep Revilla-Zúñiga
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú.
| | | | - Lizardo Cruzado
- Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi, Lima, Perú; Universidad Peruana Cayetano Heredia, Lima, Perú
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Wei D, Hu T, Hou YJ, Wang XJ, Lu JY, Ge S, Wang C, He HZ. MRGPRX2 is critical for clozapine induced pseudo-allergic reactions. Immunopharmacol Immunotoxicol 2020; 43:77-84. [PMID: 33327824 DOI: 10.1080/08923973.2020.1861006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Clozapine is one of the most widely used second-generation antipsychotics in clinic. However, allergy-like symptoms such as rash and angioedema have been reported frequently, and the mechanism is still not clear. Mas-related G protein-coupled receptor X2 (MRGPRX2) expressed on mast cells is a crucial receptor for drug induced pseudo-allergic reactions. Therefore, we explored whether the symptoms induced by clozapine were associated with allergic reaction through MRGPRX2. METHODS The effects of clozapine on pseudo-allergic reactions were evaluated by mast cells degranulation and calcium mobilization assay in vitro, and mice hindpaw swelling, serum histamine detection, avidin and H&E staining assay in vivo. The overexpressed MRGPRX2 cells membrane chromatography (MRGPRX2-HEK293/CMC), MRGPRX2-HEK293 cells calcium mobilization assay and molecular docking were applied to research the correlation between clozapine and MRGPRX2. RESULTS The study showed that clozapine induced the release of β-hexosaminidase, histamine and monocyte chemoattractant protein-1 (MCP-1), and trigged calcium mobilization in mast cells. In vivo, clozapine induced paw swelling, degranulation and vasodilation. Furthermore, clozapine could activate the calcium mobilization obviously in MRGPRX2-HEK293 cells, not in NC-HEK293 cells. Clozapine also had a good retention characteristic on MRGPRX2-HEK293/CMC column and the K D value is (2.33 ± 0.21)×10-01M. CONCLUSIONS Our findings demonstrated that clozapine could induce pseudo-allergic reactions and MRGPRX2 might be the critical receptor for it.
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Affiliation(s)
- Di Wei
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Tian Hu
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Ya-Jing Hou
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Xiang-Jun Wang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Jia-Yu Lu
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Shuai Ge
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Cheng Wang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Huai-Zhen He
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
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7
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de Filippis R, Soldevila-Matías P, De Fazio P, Guinart D, Fuentes-Durá I, Rubio JM, Kane JM, Schoretsanitis G. Clozapine-related drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a systematic review. Expert Rev Clin Pharmacol 2020; 13:875-883. [PMID: 32576056 DOI: 10.1080/17512433.2020.1787831] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe, multiorganic, and potentially life-threatening drug-induced hypersensitivity reaction, linked to several common drugs, including antiepileptics, antibiotics, and several psychotropic drugs, including clozapine. Due to the importance of clozapine in the management of treatment-resistant schizophrenia, a systematic review and characterization of clozapine-related DRESS syndrome is long overdue. AREAS COVERED This systematic review was conducted following PRISMA guidelines. PubMed, Embase, PsychINFO, and the Cochrane Library databases were independently reviewed up to 1 November 2019 for articles reporting clozapine-related DRESS syndrome cases. The RegiSCAR score system was applied to systematically characterize the clinical presentations of selected studies. EXPERT OPINION Clozapine-related DRESS syndrome was reported in six patients from four articles. Five patients received polypharmacy. Skin rash and liver involvement with elevated liver enzymes were very common. No fatal cases were found. Treatment mainly included clozapine discontinuation and immunosuppression. The mismatch between incidences of DRESS with other responsible drugs, the common misdiagnosis of this syndrome, and the fact that an extensive literature search only identified six cases suggests that clozapine-related DRESS may be overlooked. It is, therefore, necessary to optimize diagnostic strategies to identify immune-related side effects of clozapine.
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Affiliation(s)
- Renato de Filippis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro , Catanzaro, Italy
| | - Pau Soldevila-Matías
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Research Institute of Clinic University Hospital of Valencia (INCLIVA) , Valencia, Spain
| | - Pasquale De Fazio
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro , Catanzaro, Italy
| | - Daniel Guinart
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA
| | - Inmaculada Fuentes-Durá
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Valencia , Valencia, Spain
| | - Jose M Rubio
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research , Manhasset, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research , Manhasset, NY, USA
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Castanheira L, Fernandes E, Levy P, Coentre R. Aripiprazole-induced Hepatitis: A Case Report. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:551-555. [PMID: 31671495 PMCID: PMC6852676 DOI: 10.9758/cpn.2019.17.4.551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/27/2018] [Accepted: 06/26/2018] [Indexed: 12/19/2022]
Abstract
Aripiprazole is an atypical antipsychotic that acts as a partial agonist of dopamine type 2 receptors as well as 5-HT1A receptors. It is used in the treatment of schizophrenia and in type 1 bipolar disorder for mania. Because aripiprazole is well tolerated with few side effects it is used off-label in other psychotic disorders. The prevalence of abnormal liver function tests with antipsychotic use is 32%, with clinically significant effects in 4% of cases. No cases of aripiprazole-induced liver injury have been published. We report a 28-year-old female who presented with non-affective first-episode psychosis and who was treated with aripiprazole. Initially she was medicated with 10 mg per day, with an increase to 20 mg per day on the 12th day of hospitalization. Nine days after she became icteric, with nausea and had a vomiting episode. Laboratory analysis revealed a very high level of alanine aminotransferase, and minor to moderately high levels of aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. Aripiprazole was tapered and paliperidone was started with the improvement of clinical and laboratory findings.
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Affiliation(s)
- Lígia Castanheira
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Elsa Fernandes
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Pedro Levy
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal
| | - Ricardo Coentre
- Department of Psychiatry, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Portugal.,Clínica Universitária de Psiquiatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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9
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Lin J. Antipsychotics and rashes. Ment Illn 2018; 10:7808. [PMID: 30581543 PMCID: PMC6277055 DOI: 10.4081/mi.2018.7808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jessica Lin
- UC Irvine School of Medicine, Irvine, CA, USA
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10
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Hepatitis, Interstitial Nephritis, and Pancreatitis in Association With Clozapine Treatment: A Systematic Review of Case Series and Reports. J Clin Psychopharmacol 2018; 38:520-527. [PMID: 30059436 DOI: 10.1097/jcp.0000000000000922] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/BACKGROUND Clozapine is the criterion standard in treatment-resistant schizophrenia. We sought to review data on several inflammatory effects associated with clozapine, specifically interstitial nephritis, hepatitis, and pancreatitis. METHODS/PROCEDURES We conducted a systematic review to identify studies, published up until December 2017, describing clozapine-induced hepatitis, nephritis, and pancreatitis. The primary objective was to characterize the clinical characteristics associated with each of the specific inflammatory reactions to clozapine. FINDINGS/RESULTS We identified 42 cases of inflammatory reactions associated with clozapine treatment- 20 :cases of clozapine-induced hepatitis, 11 cases of nephritis, and 11 of pancreatitis. The mean (SD) age was 38.8 (11.9) years. The mean (SD) dose of clozapine used was 252.4 (133.7) mg. Time to onset of pancreatitis (17.9 [11.2] days; range 4-35 days) was shorter than that for hepatitis (34.2 [20.1] days; range, 12-90 days) and nephritis (27.9 [27.0]; range, 8-90 days) but was not statistically significant (F = 2.267, P = 0.117). The mean (SD) time to recovery was shorter for cases of pancreatitis (15.7 [18.4] days) compared with cases of hepatitis (25.9 [16.5] days) and nephritis (24.5 [18.9] days). Three cases with hepatitis died. Seven of the cases had a clozapine rechallenge (hepatitis [n = 3], nephritis [n = 1], pancreatitis [n = 3]), with 5 having a recurrence at a mean (SD) onset of 3.5 (2.5) days (range, 1-7 days); 2 hepatitis cases were successfully rechallenged. IMPLICATIONS/CONCLUSIONS Clozapine-induced hepatitis, nephritis, and pancreatitis are uncommon adverse events, reflected in the paucity of case studies in the literature. Early recognition of the signs and symptoms of clozapine-associated hepatitis, nephritis, and pancreatitis is important, as when identified, clozapine should be urgently discontinued. Clozapine is associated with evidence of benign inflammatory processes; the extent to which hepatitis, and other inflammatory reactions, may be on a continuum with these more benign and self-limiting reactions is unclear, and this can only be resolved by prospectively following cohorts of clozapine-treated patients.
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Abstract
The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.
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Telles-Correia D, Barbosa A, Cortez-Pinto H, Campos C, Rocha NBF, Machado S. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity. World J Gastrointest Pharmacol Ther 2017; 8:26-38. [PMID: 28217372 PMCID: PMC5292604 DOI: 10.4292/wjgpt.v8.i1.26] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/02/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023] Open
Abstract
The liver is the organ by which the majority of substances are metabolized, including psychotropic drugs. There are several pharmacokinetic changes in end-stage liver disease that can interfere with the metabolization of psychotropic drugs. This fact is particularly true in drugs with extensive first-pass metabolism, highly protein bound drugs and drugs depending on phase I hepatic metabolic reactions. Psychopharmacological agents are also associated with a risk of hepatotoxicity. The evidence is insufficient for definite conclusions regarding the prevalence and severity of psychiatric drug-induced liver injury. High-risk psychotropics are not advised when there is pre-existing liver disease, and after starting a psychotropic agent in a patient with hepatic impairment, frequent liver function/lesion monitoring is advised. The authors carefully review the pharmacokinetic disturbances induced by end-stage liver disease and the potential of psychopharmacological agents for liver toxicity.
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Ho YC, Lin HL. Continuation with clozapine after eosinophilia: a case report. Ann Gen Psychiatry 2017; 16:46. [PMID: 29259655 PMCID: PMC5731207 DOI: 10.1186/s12991-017-0169-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clozapine-induced eosinophilia had been reported in several studies about blood dyscrasias in clozapine-treated patient. The largest study with 2404 patients in Italy found the incidence of 2.2% by criteria of more than 0.4 × 109/l. Associated cases of pancreatitis, hepatitis, colitis, nephritis, and myocarditis were reported. Interestingly, incidence of myocarditis is high in Australia, but low in the rest of the world. In the following, we will present a case of clozapine-induced eosinophilia which spontaneous resolution was noted under continuation of clozapine. CASE PRESENTATION "Mr. L" was a 54-year-old single, jobless man. He had treatment-resistant chronic schizophrenia with onset at age 28. He had received electroconvulsive therapy twice prior to this admission. After admission, a trial of clozapine was started with an initial dose of 100 mg/day, and gradually titrated to 200 mg/day. He experienced notable improvement after 2 weeks with decreased auditory hallucinations and no more self-harm behaviors, but he also developed eosinophilia. A medical workup was performed and showed no signs of end-organ inflammation. We continued clozapine use and closely monitored complete blood count with a differential test to track his eosinophil count by the recommendation of the hematology service. His eosinophil count decreased then and remained within normal limits 3 weeks later. The dosage of clozapine was gradually raised as high as 400 mg/day. His psychotic symptoms got partial remission and continued to show no signs of end-organ inflammation at the time of discharge. CONCLUSIONS The pathophysiology of clozapine-induced eosinophilia is still unknown, but resolution of eosinophilia despite ongoing clozapine treatment suggests the possibility of an acute allergic reaction. Signs or symptoms of organ inflammation are important for management of eosinophilia. In this case report, we demonstrated that if eosinophilia occurred without signs or symptoms of organ inflammation, it may be justified to continue clozapine use under careful monitoring.
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Affiliation(s)
- Yen-Cheng Ho
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
| | - Huang-Li Lin
- Department of Psychiatry, Chang-Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan.,Chang-Gung University School of Medicine, Taoyuan City, Taiwan
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Saguem BN, Bouhlel S, Ben Salem C, Ben Hadj Ali B. Eosinophilia and parotitis occurring early in clozapine treatment. Int J Clin Pharm 2015; 37:992-5. [DOI: 10.1007/s11096-015-0163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
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Chae BJ, Kang BJ. Rash and desquamation associated with risperidone oral solution. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:414-5. [PMID: 19158986 DOI: 10.4088/pcc.v10n0511e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1030] [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]
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