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Cao Y, Xia Q, Liang J, Wang J, Shan F, Dai B. Effect of Common Cold on Serum Clozapine Concentrations in Hospitalized Patients with Schizophrenia. Neuropsychiatr Dis Treat 2024; 20:1563-1570. [PMID: 39156033 PMCID: PMC11330252 DOI: 10.2147/ndt.s473973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 08/06/2024] [Indexed: 08/20/2024] Open
Abstract
Objective The present study aims to investigate the effect of common cold on the serum clozapine concentrations in hospitalized patients with schizophrenia. Methods A total of 65 schizophrenic patients with common cold receiving clozapine treatment were retrospectively enrolled. The demographic data, medication situation, clozapine concentration, and parameters of routine haematological and biochemical laboratory tests were obtained from the medical record system. The serum clozapine concentration and clozapine concentration/dose (C/D) ratios between the baseline period and cold period were compared by paired-sample t tests. Association between the changes in serum concentration and C/D ratios of clozapine and changes in white blood cell (WBC) and neutrophil (NE) counts was evaluated using Pearson correlation analysis. Results The serum clozapine concentration (t = -9.856, P < 0.001) and clozapine C/D ratios (t = -10.071, P < 0.001) were found to be significantly elevated in the cold period compared to the baseline period. Moreover, the changes in the serum clozapine concentration were found to be significantly elevated in female patients compared to male patients (t = -2.483, P = 0.017). Furthermore, changes in the serum clozapine concentration were positively correlated to the changes in WBC (r = 0.303, P = 0.014) and NE (r = 0.315, P = 0.011) counts. Similarly, changes in clozapine C/D ratios were positively correlated to the changes in WBC (r = 0.275, P = 0.027) and NE (r = 0.328, P = 0.008) counts. Conclusion The serum clozapine concentrations in patients with schizophrenia during the common cold period were increased, which might by related to the elevated WBC and NE counts.
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Affiliation(s)
- Yin Cao
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
| | - Qingrong Xia
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
| | - Jun Liang
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
| | - Jiequan Wang
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
| | - Feng Shan
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
| | - Biao Dai
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, People’s Republic of China
- Department of Pharmacy, Hefei Fourth People’s Hospital, Hefei, People’s Republic of China
- Psychopharmacology Research Laboratory, Anhui Mental Health Center, Hefei, People’s Republic of China
- Department of Clinical Pharmacy, Anhui Clinical Research Center for Mental Disorders, Hefei, People’s Republic of China
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2
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Patel HP, Desai PH, Patel RV, Lodha SN, Gore AH, Patil PO, Desai BV, Desai DT, Vyas BA, Willcox MDP, Maulvi FA. Clozapine-laden carbon dots delivered to the brain via an intranasal pathway: Synthesis, characterization, ex vivo, and in vivo studies. Colloids Surf B Biointerfaces 2024; 237:113862. [PMID: 38518556 DOI: 10.1016/j.colsurfb.2024.113862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
Abstract
Clozapine, which is widely used to treat schizophrenia, shows low bioavailability due to poor solubility and high first-pass metabolism. The study aimed to design clozapine-loaded carbon dots (CDs) to enhance availability of the clozapine to the brain via intranasal pathway. The CDs were synthesized by pyrolysis of citric acid and urea at 200 °C by hydrothermal technique and characterized by photoluminescence, transmission electron microscopy (TEM), X-ray Photoelectron Spectrometer (XPS), and Fourier transform infrared spectrum (FTIR). The optimized clozapine-loaded CDs (CLZ-CDs-1:3-200) showed a quasi-spherical shape (9-12 nm) with stable blue fluorescence. The CDs showed high drug solubilization capacity (1.5 mg drug in 1 mg/ml CDs) with strong electrostatic interaction with clozapine (drug loading efficiency = 94.74%). The ex vivo release study performed using nasal goat mucosa showed sustained release of clozapine (43.89%) from CLZ-CDs-1:3-200 for 30 h. The ciliotoxicity study (histopathology) confirmed no toxicity to the nasal mucosal tissues using CDs. In the rat model (in vivo pharmacokinetic study), when CDs were administrated by the intranasal route, a significantly higher concentration of clozapine in the brain tissue (Cmax = 58.07 ± 5.36 μg/g and AUCt (µg/h*g) = 105.76 ± 12.31) was noted within a short time (tmax = 1 h) compared to clozapine suspension administered by intravenous route (Cmax = 20.99 ± 3.91 μg/g, AUC t (µg/h*g) = 56.89 ± 12.31, and tmax = 4 h). The high value of drug targeting efficiency (DTE, 486%) index and direct transport percentage (DTP, 58%) indicates the direct entry of clozapine-CDs in the brain via the olfactory route. In conclusion, designed CDs demonstrated a promising dosage form for targeted nose-to-brain delivery of clozapine for the effective treatment of schizophrenia.
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Affiliation(s)
- Hetal P Patel
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India.
| | - Priya H Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | | | - Sandesh N Lodha
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Anil H Gore
- Tarsadia Institute of Chemical Science, Uka Tarsadia University, Maliba Campus, Surat 394350, India
| | - Pravin O Patil
- Department of Pharmaceutical Chemistry, H. R. Patel Institute of Pharmaceutical Education and Research, Shirpur 425405, India
| | - Bhargavi V Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Ditixa T Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Bhavin A Vyas
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Furqan A Maulvi
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India; School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia.
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3
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Vaselli NM, Du Preez S, Jasenthu Kankanamage N. Clozapine-induced pneumonitis mimicking an atypical pneumonia. BMJ Case Rep 2024; 17:e259154. [PMID: 38531554 PMCID: PMC10966717 DOI: 10.1136/bcr-2023-259154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
Clozapine is an antipsychotic used for treatment-resistant schizophrenia with a significant side effect profile, including agranulocytosis, myocarditis and fever. Clozapine-induced fever often occurs in the first 2 weeks of treatment and settle after a few days. We report a case of a woman in her mid-30s who developed fever and infective symptoms suggestive of an atypical pneumonia while on clozapine titration. She was on clozapine for 16 days before developing high-grade fever, dry cough, diarrhoea, headache and photophobia with a very high CRP. We performed an extensive infection workup that returned negative results except for bilateral upper lobe ground glass changes of the lungs on CT. Despite antibiotic therapy, which would cover an atypical pneumonia, her CRP remained elevated and her fever persisted. Focus was directed to clozapine-induced pneumonitis as the cause for her symptoms. Her antibiotics were ceased, and clozapine was downtitrated. With the adjustment of her clozapine dose, her fevers and associated symptoms resolved, and CRP downtrended. Her fevers did not return when clozapine was uptitrated in the community subsequently. Clozapine-induced fever or other immune-allergic reactions should be systematically considered when patients develop fever during the initiation phase of clozapine therapy. Ruling out infective causes is desirable prior to attributing fevers to clozapine especially when they are accompanied by infective symptoms and high inflammatory markers. Careful downtitration of clozapine should be considered rather than abrupt cessation in managing clozapine-induced fevers and subsequent slow uptitration could be considered.
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Affiliation(s)
- Natasha Marcella Vaselli
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
| | - Stanley Du Preez
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Nuwan Jasenthu Kankanamage
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
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4
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Leung JG. Part
II
: Interactive case—Clinical pearls of clozapine. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023. [DOI: 10.1002/jac5.1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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5
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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6
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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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7
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Leung JG, Rakosevic DB, Courtis SN, Leloux MR, Allen ND. Iatrogenic clozapine intoxication following hospital admission: a case-based rationale for an inpatient pharmacy clozapine monitoring service. J Am Pharm Assoc (2003) 2022; 62:1711-1716. [DOI: 10.1016/j.japh.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022]
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8
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Davis EAK, Hightower T, Cinnamon KA. Toxic clozapine level as first indication of severe, acute infection. Ment Health Clin 2022; 12:45-48. [PMID: 35116212 PMCID: PMC8788300 DOI: 10.9740/mhc.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background Clozapine levels can be influenced by many factors, including pharmacogenomic variability, pharmacokinetic drug interactions, and infection/inflammation. The concentration-to-dose ratio (C/D), a measure of a medication's rate of metabolism and clearance, may increase during an acute infection due to decreased medication metabolism and clearance. Case Report A 56-year-old White man was restarted on clozapine and titrated up to 350 mg/d with therapeutic steady-state levels (C/D 1.11) on hospital day (HD) 69. At this time, he was also being treated for COPD exacerbation. For the next month, he continued to complain of cough, but vital signs and chest x-ray remained normal. Labs were unremarkable except for occasional leukocytosis that would resolve on repeat evaluation. A routine clozapine level drawn on HD 104, resulted on day 108 and showed clozapine toxicity with C/D 4.05, although the patient was asymptomatic. After receipt of labs on day 109, showing elevated WBC count, he was immediately sent to the emergency room where he was admitted for treatment of pneumonia. On return to the state hospital, the patient was continued on 100 mg clozapine and titrated to 200 mg/d based on low drug levels. He continued to do well on 200 mg/d clozapine with C/D averaging 1.13 (range, 0.75-1.52). Discussion Acute infection and illness can lead to significantly increased clozapine levels and toxicity, even if symptoms of toxicity are minimal or absent. This appears to be the first report of a toxic level being the first indication of severe medical illness.
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Affiliation(s)
| | - Tyler Hightower
- Psychiatrist and Director of Forensic Services, Springfield Hospital Center, Sykesville, Maryland
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9
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Lenoir C, Rollason V, Desmeules JA, Samer CF. Influence of Inflammation on Cytochromes P450 Activity in Adults: A Systematic Review of the Literature. Front Pharmacol 2021; 12:733935. [PMID: 34867341 PMCID: PMC8637893 DOI: 10.3389/fphar.2021.733935] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Available in-vitro and animal studies indicate that inflammation impacts cytochromes P450 (CYP) activity via multiple and complex transcriptional and post-transcriptional mechanisms, depending on the specific CYP isoforms and the nature of inflammation mediators. It is essential to review the current published data on the impact of inflammation on CYP activities in adults to support drug individualization based on comorbidities and diseases in clinical practice. Methods: This systematic review was conducted in PubMed through 7th January 2021 looking for articles that investigated the consequences of inflammation on CYP activities in adults. Information on the source of inflammation, victim drugs (and CYPs involved), effect of disease-drug interaction, number of subjects, and study design were extracted. Results: The search strategy identified 218 studies and case reports that met our inclusion criteria. These articles were divided into fourteen different sources of inflammation (such as infection, autoimmune diseases, cancer, therapies with immunomodulator…). The impact of inflammation on CYP activities appeared to be isoform-specific and dependent on the nature and severity of the underlying disease causing the inflammation. Some of these drug-disease interactions had a significant influence on drug pharmacokinetic parameters and on clinical management. For example, clozapine levels doubled with signs of toxicity during infections and the concentration ratio between clopidogrel's active metabolite and clopidogrel is 48-fold lower in critically ill patients. Infection and CYP3A were the most cited perpetrator of inflammation and the most studied CYP, respectively. Moreover, some data suggest that resolution of inflammation results in a return to baseline CYP activities. Conclusion: Convincing evidence shows that inflammation is a major factor to be taken into account in drug development and in clinical practice to avoid any efficacy or safety issues because inflammation modulates CYP activities and thus drug pharmacokinetics. The impact is different depending on the CYP isoform and the inflammatory disease considered. Moreover, resolution of inflammation appears to result in a normalization of CYP activity. However, some results are still equivocal and further investigations are thus needed.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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10
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Das A, Minner R, Krain L, Spollen J. Delirium on clozapine: A tale of friend turned foe-A case report. Int J Psychiatry Med 2021; 56:446-458. [PMID: 33148081 DOI: 10.1177/0091217420972827] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.
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Affiliation(s)
- Aparna Das
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca Minner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lewis Krain
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John Spollen
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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11
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Lenoir C, Rodieux F, Desmeules JA, Rollason V, Samer CF. Impact of Inflammation on Cytochromes P450 Activity in Pediatrics: A Systematic Review. Clin Pharmacokinet 2021; 60:1537-1555. [PMID: 34462878 PMCID: PMC8613112 DOI: 10.1007/s40262-021-01064-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Background and Objective Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not only take into account genetic, environmental, and physiological factors but also ontogeny. Published data in adults show that inflammation had an isoform-specific impact on CYP activities and we aimed to evaluate this impact in the pediatric population. Methods Articles listed in PubMed through 7 January, 2021 that studied the impact of inflammation on CYP activities in pediatrics were included in this systematic review. Sources of inflammation, victim drugs (CYP involved), effect of drug–disease interactions, number and age of subjects, and study design were extracted. Results Twenty-seven studies and case reports were included. The impact of inflammation on CYP activities appeared to be age dependent and isoform-specific, with some drug–disease interactions having significant pharmacokinetic and clinical impact. For example, midazolam clearance decreases by 70%, while immunosuppressant and theophylline concentrations increase three-fold and two-fold with intensive care unit admission and infection. Cytochrome P450 activity appears to return to baseline level when the disease is resolved. Conclusions Studies that have assessed the impact of inflammation on CYP activity are lacking in pediatrics, yet it is a major factor to consider to improve drug efficacy or safety. The scarce current data show that the impact of inflammation is isoform and age dependent. An effort must be made to improve the understanding of the impact of inflammation on CYP activities in children to better individualize treatment.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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12
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Zhang YY, Zhou XH, Shan F, Liang J. Infection is associated with elevated serum concentrations of antipsychotic drugs. Int Clin Psychopharmacol 2021; 36:264-267. [PMID: 34030168 DOI: 10.1097/yic.0000000000000366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We aimed to investigate the effects of infection on serum concentrations of different antipsychotics in inpatients with respiratory tract infections treated with psychiatric drugs, including risperidone, clozapine, quetiapine, and aripiprazole. All patients underwent therapeutic drug monitoring (TDM) and routine blood tests during infection and noninfection periods. The Wilcoxon signed-rank test was used to analyze intra-individual differences in dose-corrected serum concentrations (C/D) levels in infection and noninfection periods. To study the effects of infection intensity on drug concentrations, white blood cells (WBCs) parameters and C/D levels were analyzed by Spearman's correlation analysis using all samples. The median C/D levels of risperidone (risperidone + 9-OH, n = 36) and clozapine (n = 42) were significantly higher (P < 0.001), whereas the median C/D levels of quetiapine (n = 21) and aripiprazole (n = 13) were slightly significantly higher (P < 0.01) in infection than in noninfection period. A significant positive association between C/D levels and WBC parameters was observed for risperidone, clozapine, and quetiapine. These results indicated reduced clearance of all drugs evaluated, especially clozapine and risperidone, due to infection. Therefore, during infection in patients receiving risperidone, clozapine, quetiapine, or aripiprazole, TDM should be performed to minimize the possible adverse effects associated with elevated drug concentrations.
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Affiliation(s)
- Yuan-Yuan Zhang
- Department of Pharmacy, Hefei Fourth People's Hospital
- Psychopharmacology Research Laboratory, Anhui Mental Health Center
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
| | - Xie-Hai Zhou
- Department of Pharmacy, Hefei Fourth People's Hospital
- Psychopharmacology Research Laboratory, Anhui Mental Health Center
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
| | - Feng Shan
- Department of Pharmacy, Hefei Fourth People's Hospital
- Psychopharmacology Research Laboratory, Anhui Mental Health Center
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
| | - Jun Liang
- Department of Pharmacy, Hefei Fourth People's Hospital
- Psychopharmacology Research Laboratory, Anhui Mental Health Center
- Department of Pharmacy, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
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13
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Le DS, Su H, Liao ZL, Yu EY. Low-dose clozapine-related seizure: A case report and literature review. World J Clin Cases 2021; 9:5611-5620. [PMID: 34307616 PMCID: PMC8281419 DOI: 10.12998/wjcc.v9.i20.5611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/07/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment-resistant schizophrenia is a severe form of schizophrenia characterized by poor response to at least two antipsychotic drugs and is typically treated with clozapine. However, clozapine lowers the epileptic threshold, leading to seizures, which are severe side effects of antipsychotics that result in multiple complications. Clozapine-related seizures are generally considered to be dose-dependent and especially rare in the low-dose (150-300 mg/d) clozapine treated population. Due to clinical rarity, little is known about its clinical characteristics and treatment.
CASE SUMMARY A 62-year-old Chinese man with a 40-year history of treatment-resistant schizophrenia presented to the Emergency Department with symptoms of myoclonus, consciousness disturbance and vomiting after taking 125 mg clozapine. Upon admission, the patient had a suddenly generalized tonic-clonic seizure lasting for about half a minute with persistent disturbance of consciousness, fever, cough and bloody sputum, which was considered to be low-dose clozapine-related seizure. After antiepileptic and multiple anti-infection treatments, the patient was discharged without epileptic or psychotic symptoms.
CONCLUSION Our aim is to highlight the early prevention and optimal treatment of clozapine-related seizure through case analysis and literature review.
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Affiliation(s)
- Dan-Sheng Le
- The Second Clinical Medical College, Zhejiang Chinese Medicine University, Hangzhou 310051, Zhejiang Province, China
| | - Heng Su
- Department of Psychiatry, Zhejiang Provincial People’s Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Zheng-Luan Liao
- Department of Psychiatry, Zhejiang Provincial People’s Hospital, Hangzhou 310000, Zhejiang Province, China
| | - En-Yan Yu
- Department of Psychiatry, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou 310022, Zhejiang Province, China
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14
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:ph14060514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 01/08/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs—Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021. [DOI: 10.3390/ph14060514
expr 938544256 + 801362328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug’s pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients’ drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior—both clinically relevant in psychiatry—that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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16
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Moschny N, Hefner G, Grohmann R, Eckermann G, Maier HB, Seifert J, Heck J, Francis F, Bleich S, Toto S, Meissner C. Therapeutic Drug Monitoring of Second- and Third-Generation Antipsychotic Drugs-Influence of Smoking Behavior and Inflammation on Pharmacokinetics. Pharmaceuticals (Basel) 2021; 14:514. [PMID: 34071813 PMCID: PMC8230242 DOI: 10.3390/ph14060514&set/a 947965394+957477086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Both inflammation and smoking can influence a drug's pharmacokinetic properties, i.e., its liberation, absorption, distribution, metabolism, and elimination. Depending on, e.g., pharmacogenetics, these changes may alter treatment response or cause serious adverse drug reactions and are thus of clinical relevance. Antipsychotic drugs, used in the treatment of psychosis and schizophrenia, should be closely monitored due to multiple factors (e.g., the narrow therapeutic window of certain psychotropic drugs, the chronicity of most mental illnesses, and the common occurrence of polypharmacotherapy in psychiatry). Therapeutic drug monitoring (TDM) aids with drug titration by enabling the quantification of patients' drug levels. Recommendations on the use of TDM during treatment with psychotropic drugs are presented in the Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology; however, data on antipsychotic drug levels during inflammation or after changes in smoking behavior-both clinically relevant in psychiatry-that can aid clinical decision making are sparse. The following narrative review provides an overview of relevant literature regarding TDM in psychiatry, particularly in the context of second- and third-generation antipsychotic drugs, inflammation, and smoking behavior. It aims to spread awareness regarding TDM (most pronouncedly of clozapine and olanzapine) as a tool to optimize drug safety and provide patient-tailored treatment.
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Affiliation(s)
- Nicole Moschny
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
- Correspondence: ; Tel.: +49-511-532-3656
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Str. 4, 65346 Eltville, Germany;
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaum-Str. 7, 80336 Munich, Germany;
| | - Gabriel Eckermann
- Department of Forensic Psychiatry and Psychotherapy, Hospital Kaufbeuren, Kemnater-Str. 16, 87600 Kaufbeuren, Germany;
| | - Hannah B Maier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany;
| | - Flverly Francis
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
| | - Catharina Meissner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (H.B.M.); (J.S.); (F.F.); (S.B.); (S.T.); (C.M.)
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17
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Kutzke JL, Leung JG, May HP, Nedved AN, DeFino CE, Bennani NN. Successful Continuation of Clozapine in Conjunction With Chimeric Antigen Receptor T-Cell (CAR-T) Immunotherapy: Case Report. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e194-e197. [PMID: 33272906 DOI: 10.1016/j.clml.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
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18
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Okada M, Fukuyama K, Shiroyama T, Murata M. A Working Hypothesis Regarding Identical Pathomechanisms between Clinical Efficacy and Adverse Reaction of Clozapine via the Activation of Connexin43. Int J Mol Sci 2020; 21:ijms21197019. [PMID: 32987640 PMCID: PMC7583770 DOI: 10.3390/ijms21197019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Clozapine (CLZ) is an approved antipsychotic agent for the medication of treatment-resistant schizophrenia but is also well known as one of the most toxic antipsychotics. Recently, the World Health Organization’s (WHO) global database (VigiBase) reported the relative lethality of severe adverse reactions of CLZ. Agranulocytosis is the most famous adverse CLZ reaction but is of lesser lethality compared with the other adverse drug reactions of CLZ. Unexpectedly, VigiBase indicated that the prevalence and relative lethality of pneumonia, cardiotoxicity, and seizures associated with CLZ were more serious than that of agranulocytosis. Therefore, haematological monitoring in CLZ patients monitoring system provided success in the prevention of lethal adverse events from CLZ-induced agranulocytosis. Hereafter, psychiatrists must amend the CLZ patients monitoring system to protect patients with treatment-resistant schizophrenia from severe adverse CLZ reactions, such as pneumonia, cardiotoxicity, and seizures, according to the clinical evidence and pathophysiology. In this review, we discuss the mechanisms of clinical efficacy and the adverse reactions of CLZ based on the accumulating pharmacodynamic findings of CLZ, including tripartite synaptic transmission, and we propose suggestions for amending the monitoring and medication of adverse CLZ reactions associated with pneumonia, cardiotoxicity, and seizures.
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Affiliation(s)
- Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
- Correspondence: ; Tel.: +81-59-231-5018
| | - Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Takashi Shiroyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Masahiko Murata
- National Hospital Organization Sakakibara Hospital, 777 Sakakibara, Tsu, Mie 514-1292, Japan;
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19
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Leung JG, Wittenberger TS, Schak KM. Clozapine treated patients and COVID-19: Ensuring continued care through collaboration. Schizophr Res 2020; 222:507-508. [PMID: 32410776 PMCID: PMC7221367 DOI: 10.1016/j.schres.2020.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jonathan G Leung
- Department of Pharmacy, Mayo Clinic, Rochester, MN, Mayo Clinic - Rochester, 1216 Second Street SW, Rochester, MN 55902, United States of America.
| | - Terri S Wittenberger
- Department of Pharmacy, Mayo Clinic, Rochester, MN, Mayo Clinic - Rochester, 1216 Second Street SW, Rochester, MN 55902, United States of America
| | - Kathryn M Schak
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, Mayo Clinic - Rochester, 1216 Second Street SW, Rochester, MN 55902, United States of America
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20
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El-Ghiaty MA, Shoieb SM, El-Kadi AOS. Cytochrome P450-mediated drug interactions in COVID-19 patients: Current findings and possible mechanisms. Med Hypotheses 2020; 144:110033. [PMID: 32758877 PMCID: PMC7318945 DOI: 10.1016/j.mehy.2020.110033] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023]
Abstract
At the end of 2019, the entire world has witnessed the birth of a new member of coronavirus family in Wuhan, China. Ever since, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has swiftly invaded every corner on the planet. By the end of April 2020, almost 3.5 million cases have been reported worldwide, with a death toll of about 250,000 deaths. It is currently well-recognized that patient’s immune response plays a pivotal role in the pathogenesis of Coronavirus Disease 2019 (COVID-19). This inflammatory element was evidenced by its elevated mediators that, in severe cases, reach their peak in a cytokine storm. Together with the reported markers of liver injury, such hyperinflammatory state may trigger significant derangements in hepatic cytochrome P450 metabolic machinery, and subsequent modulation of drug clearance that may result in unexpected therapeutic/toxic response. We hypothesize that COVID-19 patients are potentially vulnerable to a significant disease-drug interaction, and therefore, suitable dosing guidelines with therapeutic drug monitoring should be implemented to assure optimal clinical outcomes.
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Affiliation(s)
- Mahmoud A El-Ghiaty
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sherif M Shoieb
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Ayman O S El-Kadi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada.
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21
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Clozapine-induced interstitial nephritis in a patient with schizoaffective disorder in the forensic setting: a case report and review of the literature. Ir J Psychol Med 2019; 39:106-111. [PMID: 31223104 DOI: 10.1017/ipm.2019.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present a rare case of Acute Interstitial Nephritis (AIN) that occurred following a re-trial of clozapine in a 56-year-old lady with schizoaffective disorder. On initial trial of clozapine, this patient felt generally unwell with respiratory symptoms. Her inflammatory markers were raised and her renal function showed a mild, transient deterioration which normalised on the day of cessation of clozapine. Two years later, clozapine was re-trialled due the refractory nature of her psychiatric symptoms. She subsequently developed renal failure and AIN was confirmed by renal biopsy. Renal function improved after cessation of clozapine; however, she never fully regained normal renal function.
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22
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Schoretsanitis G, Kane JM, Ruan CJ, Spina E, Hiemke C, de Leon J. A comprehensive review of the clinical utility of and a combined analysis of the clozapine/norclozapine ratio in therapeutic drug monitoring for adult patients. Expert Rev Clin Pharmacol 2019; 12:603-621. [DOI: 10.1080/17512433.2019.1617695] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Georgios Schoretsanitis
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Can-Jun Ruan
- Laboratory of Clinical Psychopharmacology & The National Clinical Research Centre for Mental Disorders & Beijing Key Lab of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Unbound Fraction of Clozapine Significantly Decreases with Elevated Plasma Concentrations of the Inflammatory Acute-Phase Protein Alpha-1-Acid Glycoprotein. Clin Pharmacokinet 2019; 58:1069-1075. [PMID: 31111332 PMCID: PMC6614135 DOI: 10.1007/s40262-019-00744-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background During inflammation, elevated total (unbound plus protein-bound) clozapine plasma concentrations have been observed. Elevated alpha-1-acid glycoprotein concentrations during inflammation are suggested to cause increased plasma clozapine-alpha-1-acid glycoprotein binding, resulting in elevated total clozapine plasma concentrations without significant changes in unbound concentrations. Here, we investigated the association between alpha-1-acid glycoprotein plasma concentrations and clozapine unbound fraction. Methods First, 25 and 60 µL of alpha-1-acid glycoprotein solution (20 mg/mL) were added to plasma samples (n = 3) of clozapine users (spiking experiment). Second, the association between alpha-1-acid glycoprotein plasma concentration and clozapine unbound fraction was assessed in patient samples (patient study). Samples were determined by liquid chromatography-tandem mass spectrometry. Data were analyzed with a paired t test (spiking experiment) and an unpaired t test (patient study). Results The spiking experiment showed significantly lower mean unbound fractions following 25- and 60-µL alpha-1-acid glycoprotein spikes (relative reductions of 28.3%, p = 0.032 and 43.4%, p = 0.048). In the patient study, total clozapine plasma concentrations were 10% higher in elevated (n = 6) compared with normal alpha-1-acid glycoprotein (n = 20) samples [525 µg/L vs. 479 µg/L, mean difference = 47 µg/L (95% confidence interval −217 to 310), p = 0.72]. Elevated alpha-1-acid glycoprotein samples had a 26% lower mean unbound fraction compared with normal samples [1.22% vs. 1.65%, mean difference = −0.43% (95% confidence interval −0.816 to −0.0443), p = 0.03]. Conclusions Both the spiking experiment and patient study showed a significant association between elevated alpha-1-acid glycoprotein plasma concentrations and a lower clozapine unbound fraction. Future studies should include clinical data to examine whether this association is clinically relevant, suggesting any clozapine dose adjustments.
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Yousefsani BS, Mohajeri SA, Moshiri M, Hosseinzadeh H. Liquid Chromatography Analysis of Clozapine in Rat Brain Tissue, Using its Molecularly Imprinted Polymer after Administration of Toxic Dose of Drug and Lipid Emulsion Therapy. CURR PHARM ANAL 2019. [DOI: 10.2174/1573412914666180111160741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:Molecularly imprinted polymers (MIPs) are synthetic polymers that have a selective site for a given analyte, or a group of structurally related compounds, that make them ideal polymers to be used in separation processes.Objective:An optimized molecularly imprinted polymer was selected and applied for selective extraction and analysis of clozapine in rat brain tissue.Methods:A molecularly imprinted solid-phase extraction (MISPE) method was developed for preconcentration and cleanup of clozapine in rat brain samples before HPLC-UV analysis. The extraction and analytical process was calibrated in the range of 0.025-100 ppm. Clozapine recovery in this MISPE process was calculated between 99.40 and 102.96%. The limit of detection (LOD) and the limit of quantification (LOQ) of the assay were 0.003 and 0.025 ppm, respectively. Intra-day precision values for clozapine concentrations of 0.125 and 0.025 ppm were 5.30 and 3.55%, whereas inter-day precision values of these concentrations were 9.23 and 6.15%, respectively. In this study, the effect of lipid emulsion infusion in reducing the brain concentration of drug was also evaluated.Results:The data indicated that calibrated method was successfully applied for the analysis of clozapine in the real rat brain samples after administration of a toxic dose to animal. Finally, the efficacy of lipid emulsion therapy in reducing the brain tissue concentration of clozapine after toxic administration of drug was determined.Conclusion:The proposed MISPE method could be applied in the extraction and preconcentration before HPLC-UV analysis of clozapine in rat brain tissue.
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Affiliation(s)
- Bahareh Sadat Yousefsani
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ahmad Mohajeri
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Moshiri
- Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Hosseinzadeh
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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25
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Chu CW, Liang CS. Clozapine-Associated Cytomegalovirus Colitis and Related Critical Illness in a Patient With Neither Neutropenia Nor Agranulocytosis. Ann Pharmacother 2019; 53:217-218. [PMID: 30280578 DOI: 10.1177/1060028018805866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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26
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Storelli F, Samer C, Reny JL, Desmeules J, Daali Y. Complex Drug-Drug-Gene-Disease Interactions Involving Cytochromes P450: Systematic Review of Published Case Reports and Clinical Perspectives. Clin Pharmacokinet 2018; 57:1267-1293. [PMID: 29667038 DOI: 10.1007/s40262-018-0650-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Drug pharmacokinetics (PK) is influenced by multiple intrinsic and extrinsic factors, among which concomitant medications are responsible for drug-drug interactions (DDIs) that may have a clinical relevance, resulting in adverse drug reactions or reduced efficacy. The addition of intrinsic factors affecting cytochromes P450 (CYPs) activity and/or expression, such as genetic polymorphisms and diseases, may potentiate the impact and clinical relevance of DDIs. In addition, greater variability in drug levels and exposures has been observed when such intrinsic factors are present in addition to concomitant medications perpetrating DDIs. This variability results in poor predictability of DDIs and potentially dramatic clinical consequences. The present review illustrates the issue of complex DDIs using systematically searched published case reports of DDIs involving genetic polymorphisms, renal impairment, cirrhosis, and/or inflammation. Current knowledge on the impact of each of these factors on drug exposure and DDIs is summarized and future perspectives for the management of such complex DDIs in clinical practice are discussed, including the use of advanced Computerized Physician Order Entry (CPOE) systems, the development of model-based dose optimization strategies, and the education of healthcare professionals with respect to personalized medicine.
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Affiliation(s)
- Flavia Storelli
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Jean-Luc Reny
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
- Geneva-Lausanne School of Pharmacy, University of Geneva, Geneva, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Swiss Center for Applied Human Toxicology, Geneva, Switzerland.
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27
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Clark SR, Warren NS, Kim G, Jankowiak D, Schubert KO, Kisely S, Forrester T, Baune BT, Siskind DJ. Elevated clozapine levels associated with infection: A systematic review. Schizophr Res 2018; 192:50-56. [PMID: 28392207 DOI: 10.1016/j.schres.2017.03.045] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 11/27/2022]
Abstract
Clozapine is the most effective anti-psychotic medication for treatment refractory schizophrenia. A growing number of case reports have linked infection to high clozapine levels and associated adverse outcomes. We present a systematic review of published cases to clarify the relationship between infection and elevated clozapine levels. The case reports were located through PubMed and Embase. In addition, 8 new cases from two Australian states were included. Demographics, psychiatric diagnoses and medical morbidities, medications, clinical symptoms, clozapine levels, inflammatory markers and final clinical outcome were extracted. 40 cases were identified in 23 publications that demonstrated elevated clozapine levels associated with infection. Infections were commonly respiratory in origin. Adverse events, typically sedation, were associated with raised clozapine levels during infection. In many cases the signs of infection such as fever and white blood cell count were reduced. Severe adverse effects were uncommon, with one case each of seizure, myocarditis and neutropenia. The relationship between infection, clozapine levels and adverse events is complex and multi-factorial. Monitoring of clozapine levels is essential during hospitalisation for infection and consideration should be given to gradual dose reduction to minimise dose related side effects.
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Affiliation(s)
- Scott R Clark
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - Nicola S Warren
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia.
| | - Gajin Kim
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - David Jankowiak
- Southern Adelaide Local Health Network, Adelaide, South Australia 5042, Australia
| | - Klaus Oliver Schubert
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia; Northern Adelaide Local Health Network, Adelaide, South Australia 5112, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia
| | - Tori Forrester
- Princess Alexandra Hospital, Brisbane, QLD 4012, Australia
| | - Bernhard T Baune
- University of Adelaide, Department of Psychiatry, Adelaide, SA 5005, Australia
| | - Dan J Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD 4012, Australia; University of Queensland, School of Medicine, Brisbane, QLD 4072, Australia
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Kang M, Kim E, Winkler TE, Banis G, Liu Y, Kitchen CA, Kelly DL, Ghodssi R, Payne GF. Reliable clinical serum analysis with reusable electrochemical sensor: Toward point-of-care measurement of the antipsychotic medication clozapine. Biosens Bioelectron 2017; 95:55-59. [PMID: 28412661 DOI: 10.1016/j.bios.2017.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 12/31/2022]
Abstract
Clozapine is one of the most promising medications for managing schizophrenia but it is under-utilized because of the challenges of maintaining serum levels in a safe therapeutic range (1-3μM). Timely measurement of serum clozapine levels has been identified as a barrier to the broader use of clozapine, which is however challenging due to the complexity of serum samples. We demonstrate a robust and reusable electrochemical sensor with graphene-chitosan composite for rapidly measuring serum levels of clozapine. Our electrochemical measurements in clinical serum from clozapine-treated and clozapine-untreated schizophrenia groups are well correlated to centralized laboratory analysis for the readily detected uric acid and for the clozapine which is present at 100-fold lower concentration. The benefits of our electrochemical measurement approach for serum clozapine monitoring are: (i) rapid measurement (≈20min) without serum pretreatment; (ii) appropriate selectivity and sensitivity (limit of detection 0.7μM); (iii) reusability of an electrode over several weeks; and (iv) rapid reliability testing to detect common error-causing problems. This simple and rapid electrochemical approach for serum clozapine measurements should provide clinicians with the timely point-of-care information required to adjust dosages and personalize the management of schizophrenia.
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Affiliation(s)
- Mijeong Kang
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, United States; Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States
| | - Eunkyoung Kim
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, United States; Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States
| | - Thomas E Winkler
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States; MEMS Sensors and Actuators Laboratory (MSAL), University of Maryland, College Park, MD 20742, United States
| | - George Banis
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States; MEMS Sensors and Actuators Laboratory (MSAL), University of Maryland, College Park, MD 20742, United States
| | - Yi Liu
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, United States; Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States
| | - Christopher A Kitchen
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD 21228, United States
| | - Deanna L Kelly
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD 21228, United States
| | - Reza Ghodssi
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States; MEMS Sensors and Actuators Laboratory (MSAL), University of Maryland, College Park, MD 20742, United States; Department of Electrical and Computer Engineering, Institute for Systems Research, University of Maryland, College Park, MD 20742, United States
| | - Gregory F Payne
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, United States; Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, United States.
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Bugge E, Nissen T, Wynn R. Probable clozapine-induced parenchymal lung disease and perimyocarditis: a case report. BMC Psychiatry 2016; 16:438. [PMID: 27931201 PMCID: PMC5146900 DOI: 10.1186/s12888-016-1158-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/06/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Clozapine is the archetypical atypical antipsychotic, its primary indication being treatment resistant schizophrenia. Severe side effects caused by clozapine, including leukopenia, agranulocytosis, and myocarditis, are well known. A rarely described side effect is concurrent perimyocarditis and parenchymal lung disease. CASE PRESENTATION A previously physically healthy 23-year-old male Caucasian that suffered from schizophrenia presented with flu-like symptoms 1 week after starting clozapine treatment. Treatment with clozapine was discontinued. He developed respiratory distress. Investigations showed significant parenchymal infiltration in both of the lungs, pericardial fluid, and heart failure. He initially received treatment for suspected malignant neuroleptic syndrome and later for suspected infection, but these tentative diagnoses were not confirmed. The patient's condition gradually improved. In retrospect, clozapine-induced parenchymal lung disease and perimyocarditis were deemed the most probable causes. CONCLUSIONS Concurrent perimyocarditis and parenchymal lung disease are rare side effects of clozapine. Clozapine-induced disease in general is considered an exclusion diagnosis. Lacking a verifiable diagnosis when suspecting a side effect of clozapine, clinicians might treat the most likely and serious condition presenting and consider discontinuing clozapine until the diagnostic uncertainty is reasonably resolved.
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Affiliation(s)
- Erlend Bugge
- Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway ,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Trygve Nissen
- Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway ,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Rolf Wynn
- Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
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Lee LHN, White RF, Barr AM, Honer WG, Procyshyn RM. Elevated clozapine plasma concentration secondary to a urinary tract infection: proposed mechanisms. J Psychiatry Neurosci 2016; 41:E67-8. [PMID: 27332768 PMCID: PMC4915939 DOI: 10.1503/jpn.150156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Lik Hang N Lee
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (Lee, Barr); the Department of Psychiatry, University of British Columbia (White, Honer, Procyshyn); the B.C. Psychosis Program, UBC Hospital (White, Honer, Procyshyn); and the British Columbia Mental Health and Addictions Research Institute (Barr, Honer, Procyshyn), Vancouver, B.C., Canada
| | - Randall F White
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (Lee, Barr); the Department of Psychiatry, University of British Columbia (White, Honer, Procyshyn); the B.C. Psychosis Program, UBC Hospital (White, Honer, Procyshyn); and the British Columbia Mental Health and Addictions Research Institute (Barr, Honer, Procyshyn), Vancouver, B.C., Canada
| | - Alasdair M Barr
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (Lee, Barr); the Department of Psychiatry, University of British Columbia (White, Honer, Procyshyn); the B.C. Psychosis Program, UBC Hospital (White, Honer, Procyshyn); and the British Columbia Mental Health and Addictions Research Institute (Barr, Honer, Procyshyn), Vancouver, B.C., Canada
| | - William G Honer
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (Lee, Barr); the Department of Psychiatry, University of British Columbia (White, Honer, Procyshyn); the B.C. Psychosis Program, UBC Hospital (White, Honer, Procyshyn); and the British Columbia Mental Health and Addictions Research Institute (Barr, Honer, Procyshyn), Vancouver, B.C., Canada
| | - Ric M Procyshyn
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (Lee, Barr); the Department of Psychiatry, University of British Columbia (White, Honer, Procyshyn); the B.C. Psychosis Program, UBC Hospital (White, Honer, Procyshyn); and the British Columbia Mental Health and Addictions Research Institute (Barr, Honer, Procyshyn), Vancouver, B.C., Canada
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31
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Tian DD, Wang W, Wang HN, Sze SCW, Zhang ZJ. Pharmacokinetic Evaluation of Clozapine in Concomitant Use of Radix Rehmanniae, Fructus Schisandrae, Radix Bupleuri, or Fructus Gardeniae in Rats. Molecules 2016; 21:molecules21060696. [PMID: 27240333 PMCID: PMC6272930 DOI: 10.3390/molecules21060696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 12/19/2022] Open
Abstract
Radix Rehmanniae, Fructus Schisandrae, Radix Bupleuri, and Fructus Gardeniae are often used alongside with clozapine (CLZ) for schizophrenia patients in order to reduce side effects and enhance therapeutic efficacy. However, worse outcomes were observed raising concern about a critical issue, herb-drug interactions, which were rarely reported when antipsychotics were included. This study aims to determine whether the concomitant use of these herbal medicines affects the pharmacokinetic characteristics of CLZ in rat models. Rats were given a single or multiple intraperitoneal injections of 10 mg/kg CLZ, either alone or with individual herbal water extracts administered orally. CLZ and its two inactive metabolites, norclozapine and clozapine N-oxide, were determined by high-performance liquid chromatography/tandem mass spectrometry. In the acute treatment, the formation of both metabolites was reduced, while no significant change was observed in the CLZ pharmacokinetics for any of the herbal extracts. In the chronic treatment, none of the four herbal extracts significantly influenced the pharmacokinetic parameters of CLZ and its metabolites. Renal and liver functions stayed normal after the 11-day combined use of herbal medicines. Overall, the four herbs had limited interaction effect on CLZ pharmacokinetics in the acute and chronic treatment. Herb-drug interaction includes both pharmacokinetic and pharmacodynamic mechanisms. This result gives us a hint that pharmacodynamic herb-drug interaction, instead of pharmacokinetic types, may exist and need further confirmation.
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Affiliation(s)
- Dan-Dan Tian
- School of Chinese Medicine, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, China.
| | - Wei Wang
- School of Chinese Medicine, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, China.
| | - Hua-Ning Wang
- Department of Psychiatry, the fourth Military Medical University, Xi'an 710032, Shaanxi, China.
| | - Stephen Cho Wing Sze
- School of Chinese Medicine, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, China.
| | - Zhang-Jin Zhang
- School of Chinese Medicine, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, China.
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Luo Q, Li Y, Lai Y, Zhang Z. The role of NF-κB in PARP-inhibitor-mediated sensitization and detoxification of arsenic trioxide in hepatocellular carcinoma cells. J Toxicol Sci 2016; 40:349-63. [PMID: 25972196 DOI: 10.2131/jts.40.349] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The therapeutic efficacy of arsenic trioxide (ATO) for treatments of solid tumors is restricted by its drug resistance and chemotoxicity. In this study, we investigated ATO sensitization and detoxification effect of the Poly (ADP ribose) polymerase-1 (PARP-1) inhibitor 4-Amino-1,8-naphthalimide (4AN) in the hepatocellular carcinoma cell line HepG2. We firstly reported that ATO treatment induced the activation of Nuclear factor of κB (NF-κB) and its downstream anti-apoptosis and pro-inflammatory effectors in a PARP-1-dependent manner and thus conferred HepG2 cells with ATO resistance and toxicity. 4AN significantly suppressed the ATO-induced NF-κB activation, which promotes the apoptotic response and alleviates the inflammatory reaction induced by ATO, resulting in sensitization and detoxification against ATO. We also demonstrated that the ATO-induced activation of PARP-1 and NF-κB was closely associated with the oxidative DNA damage mediated by the generated reactive oxygen species (ROS). Furthermore, the attenuation of ATO-induced ROS and the resulting oxidative DNA damage by N-acetyl-L-cysteine (NAC), a potent antioxidant, significantly reduced the activation of PARP-1 and NF-κB in ATO-treated cells. Our study provides novel insights into the mechanism of the PARP-1-mediated NF-κB signaling pathway in ATO resistance and toxicity in anticancer treatments. This study also highlights the application potential of PARP-1 inhibitors in ATO-based anti-cancer treatments and in prevention of NF-κB-mediated therapeutic resistance and toxicity.
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Affiliation(s)
- Qingying Luo
- Department of Environmental Health, West China School of Public Health, Sichuan University
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Shah RR, Smith RL. Inflammation-induced phenoconversion of polymorphic drug metabolizing enzymes: hypothesis with implications for personalized medicine. Drug Metab Dispos 2014; 43:400-10. [PMID: 25519488 DOI: 10.1124/dmd.114.061093] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Phenoconversion transiently converts genotypic extensive metabolizers (EMs) into phenotypic poor metabolizers (PMs) of drugs, potentially with corresponding changes in clinical response. This phenomenon, typically resulting from coadministration of medications that inhibit certain drug metabolizing enzymes (DMEs), is especially well documented for enzymes of the cytochrome P450 family. Nonclinical evidence gathered over the last two decades also strongly implicates elevated levels of some proinflammatory cytokines, released during inflammation, in down-regulation of drug metabolism, especially by certain DMEs of the P450 family, thereby potentially causing transient phenoconversion. Clinically, phenoconversion of NAT2, CYP2C19, and CYP2D6 has been documented in inflammatory conditions associated with elevated cytokines, such as human immunodeficiency virus infection, cancer, and liver disease. The potential of other inflammatory conditions to cause phenoconversion has not been studied but experimental and anecdotal clinical evidence supports infection-induced down-regulation of CYP1A2, CYP3A4, and CYP2C9 as well. Collectively, the evidence supports a hypothesis that certain inflammatory conditions associated with elevated proinflammatory cytokines may cause phenoconversion of certain DMEs. Since inflammatory conditions associated with elevated levels of proinflammatory cytokines are highly prevalent, phenoconversion of genotypic EM patients into transient phenotypic PMs may be more frequent than appreciated. Since drug pharmacokinetics, and therefore the clinical response, is influenced by DME phenotype rather than genotype per se, phenoconversion (whatever its cause) can have a significant impact on the analysis and interpretation of genotype-focused clinical outcome association studies. There is a risk that focusing on genotype alone may miss important associations between clinical outcomes and DME phenotypes, thus compromising future prospects of personalized medicine.
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Affiliation(s)
- Rashmi R Shah
- Rashmi Shah Consultancy Ltd., 8 Birchdale, Gerrards Cross, Buckinghamshire, United Kingdom (R.R.S.); and Department of Surgery and Cancer, Faculty of Medicine, Imperial College, South Kensington campus, London, United Kingdom (R.L.S.)
| | - Robert L Smith
- Rashmi Shah Consultancy Ltd., 8 Birchdale, Gerrards Cross, Buckinghamshire, United Kingdom (R.R.S.); and Department of Surgery and Cancer, Faculty of Medicine, Imperial College, South Kensington campus, London, United Kingdom (R.L.S.)
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Abstract
OBJECTIVE The following report presents a case in which significant clozapine toxicity was demonstrated in a patient on established therapy, in the absence of identifiable risk factors. Through this case report, the authors aim to highlight the potential for clozapine toxicity to occur unexpectedly in times of acute medical illness, and the need to remain vigilant in such situations. METHODS Case report and review of the relevant literature. RESULTS We describe a case of a 62 year old man whom developed life-threatening clozapine toxicity in the context of a severe lower respiratory infection. Following investigation to exclude the usual causes of toxicity, it was surmised that impaired CYP1A2 function, secondary to the acute inflammatory process, had led to a toxic level of the drug. CONCLUSIONS Given the possibility that serum clozapine levels may significantly rise in acute illness, the team recommends measurement of clozapine levels in these situations, in combination with the usual full blood count investigation. Such a practice should be considered in the local monitoring protocol, to avoid incidence of potentially toxic outcomes.
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Affiliation(s)
- Christina J Matthews
- Psychiatry Registrar, Hunter New England Local Health District, The Mater Hospital, Waratah, NSW, Australia
| | - Tanya L Hall
- Consultant Psychiatrist, Hunter New England Local Health District, The Mater Hospital, Waratah, NSW, Australia
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