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Mutlu E, Özçelik Eroğlu E, Coşkun FÖ, Koçyiğit D, Canpolat İKN, Avcı H, Ertuğrul A, Anıl Yağcıoğlu AE. A systematic chart review of pharmacological interventions in patients with clozapine-induced hypersalivation. Schizophr Res 2024; 268:138-144. [PMID: 37597972 DOI: 10.1016/j.schres.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES To investigate the efficacy and tolerability of medications, such as mouthwash use of 1 % atropine sulfate and tropicamide drops, oral amitriptyline and amisulpride used for clozapine-induced hypersalivation (CIH). METHODS The medical charts of inpatients with psychotic disorders between 2010 and 2022 were reviewed retrospectively. We detected 161 patients with eligible data who received or commenced clozapine. Primary outcome was defined as the percentage change in the diameter of a wet patch on the pillow (DWP) for improvements in CIH. RESULTS The frequency of CIH was 42 % (n = 68). The first step medications for CIH were tropicamide drops (49 %), atropine drops (43 %) and amitriptyline (3 %). After the first step, the median DWP significantly decreased by -33 %. During the index hospitalization, in 18 patients with persistent CIH, the median DWP significantly decreased by -42 % with the second step medications which also included amisulpride. There were no reported serious adverse events. The change in DWP was significantly correlated with the duration of clozapine treatment (r = 306) and clozapine serum level at discharge (r = 0.294). A linear regression model showed a link between the change in DWP and reduced Positive and Negative Syndrome Scale scores. CONCLUSIONS Our findings emphasize that mouthwash use of atropine or tropicamide drops has a satisfying and tolerable effect in treating CIH. Switching medications for CIH seems to be effective when CIH persists despite a first step agent. Controlled follow-up studies are needed to understand the relationship between CIH, clozapine serum levels, illness severity, and functioning.
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Affiliation(s)
- Emre Mutlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - Elçin Özçelik Eroğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - F Özlem Coşkun
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Doğukan Koçyiğit
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - İrem K N Canpolat
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Hanife Avcı
- Department of Biostatistics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - A Elif Anıl Yağcıoğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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Berloffa S, Masi G, Falcone F, Simonelli V, Narzisi A, Valente E, Viglione V, Milone A, Sesso G. Clozapine Treatment for Aggressive Behaviors in Youths with Neurodevelopmental Disorders. J Child Adolesc Psychopharmacol 2024; 34:148-156. [PMID: 38608010 DOI: 10.1089/cap.2023.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Objectives: The aim of this study was to assess effectiveness and tolerability of Clozapine in the treatment of aggression in youth with Neurodevelopmental Disorders. Methods: Patients were consecutively admitted at our third-level university hospital with nationwide catchment from June 2018 to October 2022, and followed up to July 2023. Eligibility criteria were as follows: (1) Autism Spectrum Disorder (ASD) and/or Intellectual Disability/Borderline Cognitive Functioning, (2) behavioral dyscontrol with physical aggression; (3) age range between 8 and 18 years; (4) clinical indication for Clozapine treatment after at least two failed trials with other Second-Generation Antipsychotics (SGAs); (5) availability of an at least 6-month-long follow-up. To evaluate the response to Clozapine, we used the Clinical Global Impressions (CGI) rating scales (Clinical Global Impressions-Severity [CGI-S] and Clinical Global Impressions-Improvement [CGI-I]), the Children's Global Assessment Scale (CGAS), and the Aberrant Behavior Checklist (ABC). Results: Twenty-six children and adolescents (21 boys, age 13.47 ± 2.05 years, follow-up duration 9.77 ± 3.50 months) were included in the analysis. Clinical severity (CGI-S) and functional impairment (Clinical Global Assessment Scale) significantly improved, as well as the ABC Total Score and the scores in several subscales. Sixteen patients (61.54%) were responders (CGI-I ≤2), and 13 (50.00%) displayed remission of aberrant behaviors (ΔABC-Total >35), while response/remission condition was not affected by add-on medications and psychotherapy. Most frequent side effects were increased appetite (50.00%), sialorrhea (38.46%), and increased repetitive behaviors (26.92%). Two patients presented epileptic seizures, while no patients presented leucopoenia. Conclusions: Our results suggest that Clozapine may be helpful in ameliorating treatment-resistant aggression in youth with neurodevelopmental conditions. Possible pharmacological strategies for the management of most frequent side effects are also suggested.
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Affiliation(s)
- Stefano Berloffa
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Francesca Falcone
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valerio Simonelli
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Narzisi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Elena Valente
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Valentina Viglione
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Annarita Milone
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
| | - Gianluca Sesso
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Italy
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
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Abstract
PURPOSE Hypersalivation is one of the most prevalent and distressing adverse effects associated with clozapine treatment. Currently, there is no standard therapeutic approach toward how to overcome it. Clinicians use various medications for managing this adverse effect. However, some of the agents are not effective enough, whereas others can induce other adverse effects. Recently, several reviews have been published on the treatment of clozapine-associated hypersalivation, in which the focus was on drugs from various pharmacological groups, and little attention was paid to drugs from the group of substituted benzamides. The intention of this brief narrative review is to draw the attention of clinicians to the use of the benzamide group for the treatment of this unpleasant adverse effect. METHODS A MEDLINE search was conducted to identify published treatment studies and case reports in the literature from 2000 to September 2021, concerning a treatment of clozapine-associated hypersalivation, mainly substituted benzamides. RESULTS Accumulating evidence during the last 2 decades indicates that agents derived from the benzamide group may be effective and safe agents for treatment of clozapine-associated hypersalivation. Whether with a psychotropic effect or without, medications from this group may produce a beneficial response. CONCLUSIONS Substitute benzamide derivatives have emerged as effective and well-tolerated agents for treatment clozapine-associated hypersalivation.
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Abstract
PURPOSE/BACKGROUND Antipsychotic-associated sialorrhea is a problematic adverse effect with potentially negative consequences on quality of life and medication adherence. While clozapine is the antipsychotic that is most associated with sialorrhea, there have been published reports of other second-generation antipsychotics associated with sialorrhea, including aripiprazole, olanzapine, quetiapine, and risperidone. Although drooling is mentioned within the package insert for paliperidone, to date there have been minimal published reports in which paliperidone is implicated as the offending agent. METHODS/PROCEDURES Here, we present a case of sialorrhea in a 56-year-old man with schizoaffective disorder who had a supratherapeutic paliperidone level after both oral and intramuscular paliperidone use. FINDINGS/RESULTS Paliperidone was ultimately cross tapered to aripiprazole, and the patient was given atropine drops and benztropine with resolution of the sialorrhea. We provide a review of the literature regarding the other available reports of paliperidone-associated sialorrhea, possible mechanisms behind pathophysiology, as well as reports from the World Health Organization and Food and Drug Administration adverse event reporting systems. IMPLICATIONS/CONCLUSIONS Clinicians should be aware of the potential for paliperidone and other nonclozapine second-generation antipsychotics to be associated with sialorrhea, especially given the increased frequency of their use for a variety of psychiatric disorders.
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Cuvelier E, Gressier B, Fovet T, Simon N, Décaudin B, Amad A. Prise en charge de l’hypersialorrhée iatrogène : revue de la littérature et recommandations pratiques. Encephale 2022; 48:700-711. [DOI: 10.1016/j.encep.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 10/15/2022]
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Yadav S, Takács A, Pantelis C, Thomas N. Clonidine induced sexual disinhibition in a patient with treatment-resistant schizophrenia: A case report. Aust N Z J Psychiatry 2021; 55:522. [PMID: 32720507 DOI: 10.1177/0004867420945788] [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] [Indexed: 11/15/2022]
Affiliation(s)
- Suresh Yadav
- Adult Mental Health Rehabilitation Unit, NorthWestern Mental Health, Melbourne Health, Sunshine Hospital, St Albans, VIC, Australia
| | - Anna Takács
- Adult Mental Health Rehabilitation Unit, NorthWestern Mental Health, Melbourne Health, Sunshine Hospital, St Albans, VIC, Australia
| | - Christos Pantelis
- Adult Mental Health Rehabilitation Unit, NorthWestern Mental Health, Melbourne Health, Sunshine Hospital, St Albans, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, Western Centre for Health & Education, University of Melbourne and Melbourne Health, St Albans, VIC, Australia
| | - Naveen Thomas
- Adult Mental Health Rehabilitation Unit, NorthWestern Mental Health, Melbourne Health, Sunshine Hospital, St Albans, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, Western Centre for Health & Education, University of Melbourne and Melbourne Health, St Albans, VIC, Australia
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Leung JG, Kutzke JL, Morgan RJ, Schak KM. Thrombocytopenia associated with clonidine in a case of clozapine-induced sialorrhea. Ment Health Clin 2020; 10:34-37. [PMID: 31942277 PMCID: PMC6956972 DOI: 10.9740/mhc.2020.01.034] [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] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Clozapine is approved by the US Food and Drug Administration for treatment-resistant schizophrenia and mitigation of suicidality in patients with schizophrenia or schizoaffective disorder. Clozapine requires monitoring of adverse events, such as hypotension, myocarditis, cardiomyopathy, seizures, severe neutropenia, and gastrointestinal hypomotility. Sialorrhea is another adverse event that can be bothersome for patients and result in nonadherence or the development of aspiration pneumonia. Clonidine, an α2A adrenergic receptor agonist, is one medication option that can reduce or eliminate sialorrhea. Clonidine is generally well tolerated but can contribute to hypotension and sedation. One adverse event associated with clonidine not described in the literature is thrombocytopenia. Reported is a case of clonidine-associated thrombocytopenia when used for the treatment of clozapine-induced sialorrhea.
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Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018; 17:341-356. [PMID: 30192094 PMCID: PMC6127750 DOI: 10.1002/wps.20567] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
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Affiliation(s)
- T Scott Stroup
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gray
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Maher S, Cunningham A, O'Callaghan N, Byrne F, Mc Donald C, McInerney S, Hallahan B. Clozapine-induced hypersalivation: an estimate of prevalence, severity and impact on quality of life. Ther Adv Psychopharmacol 2016; 6:178-84. [PMID: 27354906 PMCID: PMC4910403 DOI: 10.1177/2045125316641019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the prevalence and severity of clozapine-induced hypersalivation, and assess the impact hypersalivation has on global functioning. METHODS Participants attending a dedicated clozapine clinic were invited to undertake a structured interview regarding their experiences of clozapine-induced hypersalivation. Two psychometric instruments to measure hypersalivation, the Nocturnal Hypersalivation Rating Scale and the Drooling Severity and Frequency Scale were used. RESULTS Clozapine-induced hypersalivation was experienced by 92% of participants, with nocturnal hypersalivation more prevalent compared to daytime hypersalivation (85% versus 48%). Daytime drooling was severe in 18% of cases and was present on a frequent or constant basis for 20% of individuals. Hypersalivation had at least a moderate impact on the quality of life of 15% of study participants. CONCLUSIONS Clozapine-induced hypersalivation is the most prevalent adverse effect experienced by patients treated with clozapine and negatively impacts on quality of life, particularly if daytime drooling is present. The development of further strategies to ameliorate this adverse effect is required given the demonstrated lack of success to date in managing this condition.
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Affiliation(s)
- Senan Maher
- National University of Ireland Galway, Clinical Sciences Institute, Galway, Ireland
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Blissit KT, Tillery E, Latham C, Pacheco-Perez J. Glycopyrrolate for treatment of clozapine-induced sialorrhea in adults. Am J Health Syst Pharm 2015; 71:1282-7. [PMID: 25027535 DOI: 10.2146/ajhp130636] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Four cases in which glycopyrrolate was used to treat clozapine-induced sialorrhea (CIS) are reported. SUMMARY Glycopyrrolate is an antimuscarinic agent that can be used preoperatively to inhibit drooling and excessive secretions of the respiratory tract. The outcomes of four patients who received glycopyrrolate for the treatment of CIS are described. The Thomas-Stonell and Greenberg Drooling Severity and Frequency Scale (DSFS) was used retrospectively to rate patients' drooling. Glycopyrrolate was effective in alleviating CIS in cases 1-3. Two patients (cases 1 and 4) exhibited severe drooling, which caused their clothing, hands, and objects to consistently become wet. One patient (case 1) responded well to glycopyrrolate and was restarted on the medication when CIS returned after discontinuation of the drug. While another patient (case 3) displayed a similar response to therapy for CIS as the patient described in case 1, this patient did not experience the psychosocial complications as did the patient in case 1, possibly due to the use of glycopyrrolate as the initial treatment of choice. The patient in case 2 experienced moderate but frequent drooling. Thioridazine's high anticholinergic potential may have contributed to this patient's lower baseline DSFS score compared with the scores of the other three patients, or it could have augmented initial symptom improvement. CIS continued in the patient described in case 4 despite treatment with glycopyrrolate, with only mild improvement in the severity and frequency of drooling. CONCLUSION Glycopyrrolate was effective in alleviating symptoms in three of four patients with CIS. In a fourth patient, the degree of improvement was unknown due to documentation discrepancies; however, mild improvement was noted initially.
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Affiliation(s)
- Katie T Blissit
- Katie T. Blissit, Pharm.D., is Postgraduate Year 1 Pharmacy Resident, William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, SC. Erika Tillery, Pharm.D., is Clinical Pharmacist and Assistant Professor of Pharmacy Practice, School of Pharmacy, South University, Columbia. Christine Latham, B.S.Pharm., is Director of Pharmacy Services; and Jimmy Pacheco-Perez, M.D., is Chief Psychiatrist, G. Werber Bryan Psychiatric Hospital, Columbia.
| | - Erika Tillery
- Katie T. Blissit, Pharm.D., is Postgraduate Year 1 Pharmacy Resident, William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, SC. Erika Tillery, Pharm.D., is Clinical Pharmacist and Assistant Professor of Pharmacy Practice, School of Pharmacy, South University, Columbia. Christine Latham, B.S.Pharm., is Director of Pharmacy Services; and Jimmy Pacheco-Perez, M.D., is Chief Psychiatrist, G. Werber Bryan Psychiatric Hospital, Columbia
| | - Christine Latham
- Katie T. Blissit, Pharm.D., is Postgraduate Year 1 Pharmacy Resident, William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, SC. Erika Tillery, Pharm.D., is Clinical Pharmacist and Assistant Professor of Pharmacy Practice, School of Pharmacy, South University, Columbia. Christine Latham, B.S.Pharm., is Director of Pharmacy Services; and Jimmy Pacheco-Perez, M.D., is Chief Psychiatrist, G. Werber Bryan Psychiatric Hospital, Columbia
| | - Jimmy Pacheco-Perez
- Katie T. Blissit, Pharm.D., is Postgraduate Year 1 Pharmacy Resident, William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, SC. Erika Tillery, Pharm.D., is Clinical Pharmacist and Assistant Professor of Pharmacy Practice, School of Pharmacy, South University, Columbia. Christine Latham, B.S.Pharm., is Director of Pharmacy Services; and Jimmy Pacheco-Perez, M.D., is Chief Psychiatrist, G. Werber Bryan Psychiatric Hospital, Columbia
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Kreinin A, Miodownik C, Sokolik S, Shestakova D, Libov I, Bergman J, Lerner V. Amisulpride versus moclobemide in treatment of clozapine-induced hypersalivation. World J Biol Psychiatry 2011; 12:620-6. [PMID: 20964499 DOI: 10.3109/15622975.2010.527370] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Previous publications demonstrated substitute benzamides as effective agents in treatment of clozapine-induced sialorrhea (CIS). The aim of this study was to compare efficacy of amisulpride and moclobemide (both from the substitute benzamide group) in controlling, or at least minimizing, CIS. METHODS The study was designed as a 6-week, two-center, fixed-dose, comparison study of 400 mg/day of amisulpride versus 300 mg/day of moclobemide as an adjunctive treatment in 53 schizophrenia and schizoaffective disorder patients (diagnosed according to DSM-IV) suffering from CIS. The patients were treated with each medication during 2 weeks, followed by a washout period of 2 weeks. Primary outcome measures included the reduction in the five-point Nocturnal Hypersalivation Rating Scale (NHRS). Secondary outcomes included the Positive and Negative Syndrome Scale (PANSS), Manic State Assessment Scale, and Extrapyramidal Symptom Rating Scale (ESRS). RESULTS Both amisulpride and moclobemide were very effective in reducing CIS. Almost 74% of patients treated with amisulpride and 83% of patients treated with moclobemide showed some level of improvement on NHRS. Only in one patient treated with amisulpride, CIS worsened. CONCLUSIONS Both medications were safe and effective as treatment of CIS. Although moclobemide exceeded amisulpride in antisalivation activity, treatment of CIS with amisulpride leads to improvement in psychotic symptoms.
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Affiliation(s)
- Anatoly Kreinin
- Mental Health Center Tirat Carmel, Bruce Rapaport Faculty of Medicine Technion-Haifa, Israel
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Abstract
OBJECTIVE Clozapine treatment remains the gold standard for treatment-resistant schizophrenia, but treatment with clozapine is associated with several side-effects that complicate the use of the drug. This clinical overview aims to provide psychiatrists with knowledge about how to optimize clozapine treatment. Relevant strategies for reducing side-effects and increasing the likelihood of response are discussed. METHOD Studies of clozapine available in MEDLINE were reviewed. RESULTS A slow up-titration of clozapine is recommended in order to reach the optimal dosage of clozapine and diminish the risk of dose-dependent side-effects. Particularly, in case of partial response or non-response, the use of therapeutic drug monitoring of clozapine is recommended. Plasma levels above the therapeutic threshold of 350-420 ng/ml are necessary to determine non-response to clozapine. To ease the burden of dose-dependent side-effects, dose reduction of clozapine should be tried and combination with another antipsychotic drug may facilitate further dose reduction. For most side-effects, counteracting medication exists. Augmentation with lamotrigine, antipsychotics, or electroconvulsive therapy may be beneficial in case of partial response to clozapine. CONCLUSION Treatment with clozapine should be optimized in order to increase the rate of response and to minimize side-effects, thus diminishing the risk of discontinuation and psychotic relapse.
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Affiliation(s)
- J Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Denmark.
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Bird AM, Smith TL, Walton AE. Current Treatment Strategies for Clozapine-Induced Sialorrhea. Ann Pharmacother 2011; 45:667-75. [DOI: 10.1345/aph.1p761] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To provide an understanding of the underlying pathophysiology and current treatment options for clozapine-induced sialorrhea. Data Sources: Literature was retrieved through MEDLINE (1977-February 2011) using the key search terms clozapine, sialorrhea, hypersalivation, drooling, and treatment. In addition, reference citations from identified publications were reviewed. Study Selection and Data Extraction: All articles published in English identified from the data source were evaluated and included in the review. Data Synthesis: Sialorrhea is a common and disabling adverse effect of clozapine use. Current treatment options include topical and oral antimuscarinic medications and α-adrenergic agents. New areas of investigation include glycopyrrolate, botulinum toxin, and substitute benzamide derivatives. Thirteen clinical trials (2 retrospective, 5 open-label, 6 double-blind) and 13 case reports were reviewed. Overall, there are weak data on use of antimuscarinic agents, consisting mostly of small open-label or retrospective studies. Glycopyrrolate, however, demonstrated significant reduction of hypersalivation in a randomized controlled trial. Medications with activity at α-adrenergic receptors have shown positive results in case reports, retrospective evaluations, and an open-label trial, but have not been investigated in a double-blind, controlled fashion. Botulinum toxin also significantly improved sialorrhea in both a case report and double-blind study, although the trial included hypersalivation from other etiologies in addition to clozapine. Substitute benzamide derivatives have demonstrated significant improvements in randomized controlled trials; however, they are not available in the US. Overall, few treatment strategies have been evaluated in controlled settings, warranting further randomized controlled trials to identify more effective treatment options. Conclusions: Current pharmacologic treatment options for clozapine-induced sialorrhea are limited in number and efficacy. Although few randomized controlled trials have been conducted, this review identifies potential treatment alternatives for this common and sometimes severe adverse effect.
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Affiliation(s)
- Angela M Bird
- College of Pharmacy, The University of Texas, Austin, TX
| | - Tawny L Smith
- PGY 1 and PGY 2 (Psychiatry), Seton Family of Hospitals; Assistant Professor, Department of Psychiatry, The University of Texas Southwestern Medical Center at Seton Family of Hospitals; Adjunct Assistant Professor, College of Pharmacy, The University of Texas, Austin
| | - Amy E Walton
- The University of Texas Southwestern Medical Center at Seton Family of Hospitals
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Dardennes RM, Al Anbar NN, Rouillon F. Successful augmentation of clozapine-resistant treatment of schizophrenia with clonidine. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:724-5. [PMID: 20307621 DOI: 10.1016/j.pnpbp.2010.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 03/10/2010] [Accepted: 03/15/2010] [Indexed: 11/18/2022]
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Abstract
Clozapine has been used in the treatment of schizophrenia for about two decades and extensive data have been accumulated with regard to its use in various parts of the world. However, in contrast to Western countries, there are few studies which have evaluated the usefulness of clozapine in Indian patients. This article attempts to review the available data on clozapine originating from India. This review reflects the fact that there are few studies from the Indian subcontinent and most of these are case reports. In view of the same, there is a need for further research to evaluate the effectiveness of clozapine in India.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India
| | - Alakananda Dutt
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India
| | - Ajit Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India
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Galletly C. Recent advances in treating cognitive impairment in schizophrenia. Psychopharmacology (Berl) 2009; 202:259-73. [PMID: 18766331 DOI: 10.1007/s00213-008-1302-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 08/10/2008] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Schizophrenia is often associated with chronic disability and poor outcome. In addition to positive symptoms, such as hallucinations and delusions, and negative symptoms including poverty of speech and blunted affect, schizophrenia is also associated with deficits in cognitive function. It has been increasingly recognized that the severity of cognitive impairment is a major determinant of outcome. Therefore, interventions to improve cognitive function also have the capacity to improve quality of life and social and occupational outcomes. Whilst some of the antipsychotic drugs have shown some selective benefits, there is some controversy about the extent of these benefits. OBJECTIVES This article provides an overview of research into drugs that might enhance cognition in schizophrenia. CONCLUSION Drugs such as modafanil and galantamine are being evaluated, and a number of new drugs are currently in development. Standardized cognitive assessment measures are being developed so studies can be compared more easily. This field is advancing rapidly, but as yet, no widely applicable, evidence-based treatments are available to the clinician.
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Affiliation(s)
- Cherrie Galletly
- Discipline of Psychiatry, School of Medicine, University of Adelaide, Suite 13, The Adelaide Clinic Consulting Suites, 33 Park Tce Gilberton, Adelaide, South Australia 5081, Australia.
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Robb AS, Lee RH, Cooper EB, Siedel JV, Nusrat N. Glycopyrrolate for treatment of clozapine-induced sialorrhea in three adolescents. J Child Adolesc Psychopharmacol 2008; 18:99-107. [PMID: 18294092 DOI: 10.1089/cap.2007.0037] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this case study was to report preliminary data on the effectiveness and tolerability of glycopyrrolate for the treatment of clozapine-induced sialorrhea, or excessive flow of saliva, in an adolescent population. METHOD Three adolescent females (age 13-16), who developed sialorrhea secondary to clozapine treatment, received an open-label trial of glycopyrrolate (4-8 mg) during inpatient hospitalization for treatment-resistant psychotic illness. RESULTS The target symptom of sialorrhea was improved in all three cases, with patient self-reports of decreased production of saliva confirmed by staff observation. Glycopyrrolate was generally well tolerated by the patients. One patient reported constipation, which improved with symptomatic treatment. A second patient reported dry mouth, which improved with a reduction in dose of glycopyrrolate. CONCLUSIONS These three cases provide support for the potential effectiveness and tolerability of glycopyrrolate for clozapine-induced sialorrhea in adolescents. Further controlled studies are required to determine the safety, efficacy and tolerability of glycopyrrolate in this age group and in adults for clozapine-induced sialorrhea.
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Affiliation(s)
- Adelaide S Robb
- Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, 111 Michigan Avenue NW, Washington, D.C., USA.
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Sockalingam S, Shammi C, Remington G. Clozapine-induced hypersalivation: a review of treatment strategies. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2007; 52:377-84. [PMID: 17696024 DOI: 10.1177/070674370705200607] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Clozapine-induced hypersalivation (CIH) is a significant side effect affecting about one-third of patients treated with clozapine. CIH can be stigmatizing, can affect quality of life, and can result in discontinuation of clozapine treatment. The purpose of this review is to provide an understanding of CIH, specifically, its pathophysiology, measurement, and the evidence for CIH treatment alternatives. METHODS We searched MEDLINE from 1980 to June 2006 for all reported pharmacologic treatment studies related to CIH. We identified additional references by a manual search of the bibliographies of retrieved articles. RESULTS Several studies reported improvement of CIH with both selective and nonselective anticholinergic medications. However, with the exception of local anticholinergic agents such as ipratropium bromide and atropine eye drops, potential systemic adverse effects limit the effectiveness of this class of medications. Open-label studies of clonidine, an alpha2 antagonist, suggest that it may be beneficial in managing CIH. Other pharmacologic treatments, such as amisulpride and botulinum toxin, may be useful in refractory CIH cases. CONCLUSION Although few randomized controlled trials were found in the literature, this review highlights potential treatment alternatives for this common and disabling cause of hypersalivation. Prompt and effective treatment of CIH may assist with treatment tolerability, adherence, and outcomes in patients with treatment-refractory schizophrenia. Information on funding and support and author affiliations appears at the end of the article.
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Praharaj SK, Arora M, Gandotra S. Clozapine-induced sialorrhea: pathophysiology and management strategies. Psychopharmacology (Berl) 2006; 185:265-73. [PMID: 16514524 DOI: 10.1007/s00213-005-0248-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Accepted: 10/26/2005] [Indexed: 11/30/2022]
Abstract
RATIONALE Clozapine is an atypical antipsychotic agent with proven efficacy in refractory schizophrenia, but its widespread use is limited by adverse effects such as agranulocytosis, seizures, sedation, weight gain, and sialorrhea. Clozapine-induced sialorrhea (CIS) is bothersome and has socially stigmatizing adverse effects, which result in poor treatment compliance. The pathophysiology of this condition is poorly understood and the treatment options available are based mostly on case reports and open-label studies. OBJECTIVE To review the available studies on CIS. METHOD All relevant studies available through PUBMED search supplemented with manual search were undertaken. RESULT The clinical features, complications, assessment, pathophysiology, and management of CIS are discussed. CONCLUSION Although the studies evaluating the therapeutic options has limitations and no drug has been found to be superior, judicious use of pharmacological agents along with behavioral methods will reduce this troublesome side effect and enhance compliance.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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