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Schoretsanitis G, Anıl Yağcıoğlu AE, Ruan CJ, Eap CB, Molden E, Baptista T, Clark SR, Fernandez-Egea E, Kim SH, Lane HY, Leung J, Maroñas Amigo O, Motuca M, Olmos I, Every-Palmer S, Procyshyn RM, Rohde C, Satish S, Schulte PFJ, Spina E, Takeuchi H, Verdoux H, Correll CU, de Leon J. Clozapine ultrarapid metabolism during weak induction probably exists but requires careful diagnosis. A literature review, five new cases and a proposed definition. Schizophr Res 2024; 268:302-307. [PMID: 37268453 DOI: 10.1016/j.schres.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/04/2023]
Abstract
During weak induction (from smoking and/or valproate co-prescription), clozapine ultrarapid metabolizers (UMs) need very high daily doses to reach the minimum therapeutic concentration of 350 ng/ml in plasma; clozapine UMs need clozapine doses higher than: 1) 900 mg/day in patients of European/African ancestry, or 2) 600 mg/day in those of Asian ancestry. Published clozapine UMs include 10 males of European/African ancestry, mainly assessed with single concentrations. Five new clozapine UMs (two of European and three of Asian ancestry) with repeated assessments are described. A US double-blind randomized trial included a 32-year-old male smoking two packages/day with a minimum therapeutic dose of 1,591 mg/day from a single TDM during open treatment of 900 mg/day. In a Turkish inpatient study, a 30-year-old male smoker was a possible clozapine UM needing a minimum therapeutic dose of 1,029 mg/day estimated from two trough steady-state concentrations on 600 mg/day. In a Chinese study, three possible clozapine UMs (all male smokers) were identified. The clozapine minimum therapeutic dose estimated with trough steady-state concentrations >150 ng/ml was: 1) 625 mg/day, based on a mean of 20 concentrations in Case 3; 2) 673 mg/day, based on a mean of 4 concentrations in Case 4; and 3) 648 mg/day, based on a mean of 11 concentrations in Case 5. Based on these limited studies, clozapine UMs during weak induction may account for 1-2% of clozapine-treated patients of European ancestry and <1% of those of Asian ancestry. A clozapine-to-norclozapine ratio <0.5 should not be used to identify clozapine UMs.
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Affiliation(s)
- Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland; Division of Psychiatry Research, Northwell Health, The Zucker Hillside Hospital, New York, NY, USA; Department of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
| | | | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland; Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, PO Box 23 Vinderen, 0319 Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Trino Baptista
- Department of Physiology, Los Andes University Medical School, Mérida, Venezuela; Medical School, Anáhuac University, Querétaro, Mexico; Neuroorigen, Querétaro, Mexico
| | - Scott R Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, Australia.
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Hsien-Yuan Lane
- Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Jonathan Leung
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.
| | - Olalla Maroñas Amigo
- Genomic Medicine Group, Galician Public Foundation of Genomic Medicine (FPGMX), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Galicia, Spain; Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain; Center for Biomedical Research in Rare Diseases Network, Carlos III Health Institute, Madrid, Spain.
| | - Mariano Motuca
- Department of Psychiatry, School of Medicine at Universidad Nacional de Cuyo, Mendoza, Argentina
| | - Ismael Olmos
- Clinical Pharmacology Unit, Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud (ASSE), Montevideo, Uruguay.
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand.
| | - Ric M Procyshyn
- Department of Psychiatry, University of British Columbia, Vancouver, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada.
| | - Christopher Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Suhas Satish
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, Netherlands; Dutch Clozapine Collaboration Group, Castricum, Netherlands.
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Christoph U Correll
- Division of Psychiatry Research, Northwell Health, The Zucker Hillside Hospital, New York, NY, USA; Department of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain.
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de Leon J. Promoting safer and wider worldwide use of clozapine. Schizophr Res 2024; 268:1-6. [PMID: 38519290 DOI: 10.1016/j.schres.2024.03.003] [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: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
This issue focuses on the past, the present and the future of clozapine. Of the 43 clozapine articles, nine are historical articles dealing with the past, 29 deal with the present and five with laboratory assays which may influence its future use. These 43 articles include 219 different authors from 56 countries/regions and five continents.
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Affiliation(s)
- Jose de Leon
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA; Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain.
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de Leon J, Arrojo-Romero M, Verdoux H, Ruan CJ, Schoretsanitis G, Rohde C, Cohen D, Schulte PFJ, Kim SH, Cotes RO, Leung JG, Otsuka Y, Kirilochev OO, Baptista T, Grover S, Every-Palmer S, Clark SR, McGrane IR, Motuca M, Olmos I, Wilkowska A, Sagud M, Anıl Yağcıoğlu AE, Ristic DI, Lazary J, Sanz EJ, De Las Cuevas C. Escaping the Long Shadow Cast by Agranulocytosis: Reflections on Clozapine Pharmacovigilance Focused on the United Kingdom. J Clin Psychopharmacol 2023; 43:239-245. [PMID: 37068034 DOI: 10.1097/jcp.0000000000001678] [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: 04/18/2023]
Abstract
PURPOSE/BACKGROUND A recent article in this journal presented a US perspective regarding the modernization of clozapine prescription and proposed an escape from the long shadow cast by agranulocytosis. METHODS Here, an international group of collaborators discusses a point of view complementary to the US view by focusing on worldwide outcomes of clozapine usage that may be uneven in terms of frequency of clozapine adverse drug reactions. FINDINGS/RESULTS Studies from the Scandinavian national registries (Finland and Denmark) did not find increased mortality in clozapine patients or any clear evidence of the alleged toxicity of clozapine. Data on clozapine-associated fatal outcomes were obtained from 2 recently published pharmacovigilance studies and from the UK pharmacovigilance database. A pharmacovigilance study focused on physician reports to assess worldwide lethality of drugs from 2010 to 2019 found 968 clozapine-associated fatal outcomes in the United Kingdom. Moreover, the United Kingdom accounted for 55% (968 of 1761) of worldwide and 90% (968 of 1073) of European fatal clozapine-associated outcomes. In a pharmacovigilance study from the UK database (from 2008 to 2017), clozapine was associated with 383 fatal outcomes/year including all reports from physicians and nonphysicians. From 2018 to 2021, UK clozapine-associated fatal outcomes increased to 440/year. IMPLICATIONS/CONCLUSIONS The interpretation of fatal outcomes in each country using pharmacovigilance databases is limited and only allows gross comparisons; even with those limitations, the UK data seem concerning. Pneumonia and myocarditis may be more important than agranulocytosis in explaining the uneven distribution of fatal outcomes in clozapine patients across countries.
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Affiliation(s)
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | | | | | | | | | | | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | | | - Yuji Otsuka
- Department of Psychiatry, Asahi General Hospital, Chiba, Japan
| | - Oleg O Kirilochev
- Department of Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Russian Federation
| | | | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Scott R Clark
- University of Adelaide, Discipline of Psychiatry, Adelaide, South Australia, Australia
| | - Ian R McGrane
- Department of Pharmacy Practice, University of Montana, Missoula, MT
| | - Mariano Motuca
- Instituto Vilapriño, Center for Studies, Assistance and Research in Neurosciences, Mendoza, Argentina
| | - Ismael Olmos
- Clinical Pharmacology Unit and Pharmacy Department, Vilardebó Hospital, Administración de Servicios de Salud, Montevideo, Uruguay
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | | | - Judit Lazary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | | | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Canary Islands, Spain
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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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The Modernization of Clozapine: A Recapitulation of the Past in the United States and the View Forward. J Clin Psychopharmacol 2022; 42:565-580. [PMID: 36170148 DOI: 10.1097/jcp.0000000000001606] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Although clozapine was Food and Drug Administration (FDA) approved more than 3 decades ago, major barriers and gaps in knowledge continue to prevent its effective and safe use. We review modern-day problems encountered with clozapine in the United States (US). METHODS Information surrounding current administrative, clinical, research, and technological gaps or barriers related to clozapine use in the US was reviewed. FINDINGS The history of how clozapine became FDA approved likely contributes to gaps in knowledge. The frequency of safety warnings added to the FDA prescribing information may add to fears about clozapine, as evidence by numerous published survey studies. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program has been modified several times in the last decade, causing access and safety issues for patients, which are discussed. Evidence may suggest that the FDA REMS requirements for hematologic monitoring are too cumbersome, and there may be ability to safely loosen requirements. The COVID-19 pandemic brought forth the ability for extended interval monitoring but also greater awareness of the clozapine-inflammation interaction. Newer guidelines published describe considerations in personalizing clozapine titration based on principles of ethnopsychopharmacology. Emerging technologies to support the use of clozapine are not widely available. IMPLICATIONS Clozapine is a unique life-saving drug but it is underused in the US, despite its established efficacy. The 2021 REMS changes led to significant difficulties for providers and patients. We highlight the importance of the clozapine-inflammation interaction, therapeutic drug monitoring, and the ability for individual care based on patient-specific factors. There is an urgent need for advancing technology used for clozapine monitoring, evaluating barriers created by REMS, and establishing consistent practices throughout the US.
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De Las Cuevas C, Arrojo-Romero M, Ruan CJ, Schoretsanitis G, Sanz EJ, de Leon J. Clozapine-induced myocarditis in children and adolescents: a pharmacovigilance study using VigiBase and a systematic literature review. Expert Opin Drug Metab Toxicol 2022; 18:715-727. [PMID: 36526610 DOI: 10.1080/17425255.2022.2160318] [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: 12/23/2022]
Abstract
INTRODUCTION Clozapine-induced myocarditis in children (age ≤18 yo) was studied from a PubMed search (18 July 2022) (9 cases) and from the World Health Organization's pharmacovigilance database, called Vigibase, of adverse drug reaction (ADR) reports (72 non-duplicated cases). VigiBase uses a logarithmic measure of disproportionality called the information component (IC). A logistic regression model of presence/absence (40/32) of seriousness in VigiBase was developed. AREAS COVERED VigiBase provided a significant myocarditis IC = 4.2 with an IC025 = 3.8; only 4 clozapine-induced myocarditis cases were expected, while 72 were observed. The PubMed search identified 9 cases, while VigiBase identified 72 cases (of which 67 did not overlap with published cases). These 76 combined cases included 35 doubtful (most with missing information on the day of diagnosis), 19 possible and 22 probable, according to the ADR scale. After adjusting for confounders, quetiapine increased the risk of seriousness with an odds ratio (OR) of 17.6 (95% confidence interval CI, 1.56 to 198.6), while Australian origin decreased it with an OR = 0.13 (CI, 0.04 to 0.47). EXPERT OPINION These 41 cases of at least possible clozapine-induced myocarditis indicated that this ADR can definitively occur in children, particularly in the first 30 days of up-titration. Children's and adult cases appeared similar.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine and Instituto Universitario de Neurociencia (IUNE) University of La Laguna, Canary Islands, Spain.,Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA
| | - 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
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, US.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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de Leon J, Ruan CJ, Schoretsanitis G, Rohde C, Yağcıoğlu EA, Baptista T, Kirilochev OO, De Las Cuevas C, Correll CU. An international guideline with six personalised titration schedules for preventing myocarditis and pneumonia associated with clozapine. Gen Psychiatr 2022; 35:e100773. [PMID: 35866000 PMCID: PMC9244675 DOI: 10.1136/gpsych-2022-100773] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022] Open
Abstract
White blood cell (WBC) monitoring has reduced clozapine-treated patient deaths associated with agranulocytosis to a rarity. However, clozapine protocols and package inserts worldwide provide no instructions for preventing myocarditis or pneumonia during clozapine titrations. Prescribers worldwide are largely unaware of that. Meanwhile, as they worry about agranulocytosis, their clozapine-treated patients are at risk of dying from pneumonia or myocarditis. Consequently, an international guideline with 104 authors from 50 countries/regions was recently published to provide personalised clozapine titration schedules for adult inpatients. This forum article reviews pneumonia and myocarditis occurring during clozapine titration, as well as the three most innovative aspects of this new guideline: (1) personalised titration, (2) C reactive protein (CRP) measures, and (3) dose predictions based on blood levels. Clozapine metabolism is influenced by 3 levels of complexity: (1) ancestry groups, (2) sex-smoking subgroups, and (3) presence/absence of poor metabolizer status. These 3 groups of variables should determine the maintenance dose and speed of clozapine titration; they are summarised in a table in the full-text. The international clozapine titration guideline recommends measuring CRP levels simultaneously with WBC, at baseline and weekly at least for the first 4 weeks of titration, the highest risk period for clozapine-induced myocarditis.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Hospital Santiago Apóstol, Vitoria-Gasteiz, Spain
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology, Beijing An Ding Hospital, Beijing, China.,The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing An Ding Hospital, Beijing, China
| | - Georgios Schoretsanitis
- Psychiatry, University of Zürich, Zurich, Switzerland.,Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Christopher Rohde
- Affective Disorders, Aarhus University Hospital, Aarhus, Denmark.,Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Trino Baptista
- Physiology, Los Andes University Medical School, Merida, Bolivarian Republic of Venezuela
| | - Oleg O Kirilochev
- Clinical Pharmacology, Astrakhan State Medical University, Astrakhan, Astrahanskaâ, Russian Federation
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Christoph U Correll
- Psychiatry Research, Zucker Hillside Hospital, Glen Oaks, New York, USA.,Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
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