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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024:10.1007/s40263-024-01100-4. [PMID: 38951464 DOI: 10.1007/s40263-024-01100-4] [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] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Clapham E, Reutfors J, Linder M, Brandt L, Sundström J, Bodén R. The association between exposure to clozapine, olanzapine, and quetiapine and the outcomes perimyocarditis and heart failure: A population-based cohort study. Psychiatry Res 2023; 326:115336. [PMID: 37451082 DOI: 10.1016/j.psychres.2023.115336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
The risk of cardiac adverse events following clozapine use is debated and is unknown for the chemically related and widely used antipsychotics olanzapine and quetiapine. National Swedish registers were used to identify all patients 16-75 years old with antipsychotic dispensations between 2005 and 2018. The short-term outcome was a diagnosis of perimyocarditis (pericarditis and/or myocarditis) within two months of first dispensation, and the long-term outcome was heart failure (including cardiomyopathy) within three years. Cox regressions with time varying exposure were used to estimate hazard rates (HR) and their 95% confidence intervals (CI). A total of 201,045 individuals were included in the cohort. The risk of developing perimyocarditis during clozapine treatment tripled compared to no antipsychotic treatment (HR 3.4, CI 1.6-7.3), although the absolute rate remained comparably low. The long-term risk of heart failure during clozapine treatment was also elevated (HR 1.3, CI 1.1-1.7). Treatment with either or both olanzapine or quetiapine was not associated with an increased relative risk of perimyocarditis, or heart failure compared to no antipsychotic treatment. Clozapine use is therefore associated with a substantially elevated short-term risk of perimyocarditis and an increased risk of heart failure within three years.
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Affiliation(s)
- Eric Clapham
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden; Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden.
| | - Johan Reutfors
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Marie Linder
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology (CPE), Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden
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Buda V, Prelipcean A, Cozma D, Man DE, Negres S, Scurtu A, Suciu M, Andor M, Danciu C, Crisan S, Dehelean CA, Petrescu L, Rachieru C. An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure. J Clin Med 2022; 11:2020. [PMID: 35407628 PMCID: PMC8999552 DOI: 10.3390/jcm11072020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022] Open
Abstract
Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.
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Affiliation(s)
- Valentina Buda
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Andreea Prelipcean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
| | - Dragos Cozma
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dana Emilia Man
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Simona Negres
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, Traian Vuia 6, 020956 Bucharest, Romania;
| | - Alexandra Scurtu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Maria Suciu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Minodora Andor
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
| | - Corina Danciu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Simina Crisan
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Cristina Adriana Dehelean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Lucian Petrescu
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Ciprian Rachieru
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Center for Advanced Research in Cardiovascular Pathology and Hemostasis, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
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Klein N, Barnett L, Guirgis H, Stearns WH. Transient Clozapine-induced Myocarditis Without Discontinuation of Medication: A Series of 2 Patients. J Psychiatr Pract 2022; 28:170-175. [PMID: 35238829 DOI: 10.1097/pra.0000000000000618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clozapine, an antipsychotic medication used to treat treatment-refractory schizophrenia, has been associated with various dangerous side effects, including myocarditis. However, there have been few published cases reporting on patients with clozapine-induced myocarditis confirmed by cardiac magnetic resonance imaging or the management, treatment, and follow-up of these patients. METHODS This report describes 2 cases of patients with treatment-refractory schizophrenia evidencing transient clozapine-induced myocarditis. Detailed information including laboratory values, imaging results, and clinical notes were gathered. FINDINGS The 2 cases demonstrated differing manifestations of clozapine-induced myocarditis. Both cases showed that such myocarditis can be transient and can be treated clinically with close observation without discontinuation of clozapine. IMPLICATIONS These cases show that clozapine-induced myocarditis is transient at times and can self-resolve without discontinuation of clozapine. These observations may suggest a change in clinical practice so that, with close observation, we can avoid risking psychiatric decompensation in select patients with a history of treatment-resistant schizophrenia.
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Affiliation(s)
- Nadav Klein
- KLEIN, BARNETT, GUIRGIS, and STEARNS: Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH
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He L, Yu Y, Wei Y, Huang J, Shen Y, Li H. Characteristics and Spectrum of Cardiotoxicity Induced by Various Antipsychotics: A Real-World Study From 2015 to 2020 Based on FAERS. Front Pharmacol 2022; 12:815151. [PMID: 35185550 PMCID: PMC8854762 DOI: 10.3389/fphar.2021.815151] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to investigate the characteristics and spectrum of cardiotoxicity induced by various antipsychotics based on the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database. Methods: Data of the FAERS database from the first quarter of 2015 to the fourth quarter of 2020 were downloaded for disproportionality analysis. The significant signal was evaluated by reporting odds ratios and information components with statistical shrinkage transformation. Results: A total of 2,361,487 records were extracted for disproportionality analysis. Among the 10 antipsychotics, clozapine and amisulpride performed strong cardiotoxicity. Cardiomyopathy, cardiac arrhythmia, and Torsade de pointes/QT prolongation were the common cardiac adverse event induced by antipsychotics. Different characteristics of the spectrum of cardiotoxicity in various APs were discovered after further data mining. Moreover, evidence of the association between antipsychotics and eosinophilic myocarditis, peripartum cardiomyopathy was provided in this study. Conclusion: Antipsychotics presented cardiotoxicity in different degrees, and more cardiac examinations should be monitored in patients with antipsychotics.
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Affiliation(s)
| | | | | | - Jingjing Huang
- *Correspondence: Huafang Li, ; Yifeng Shen, ; Jingjing Huang,
| | - Yifeng Shen
- *Correspondence: Huafang Li, ; Yifeng Shen, ; Jingjing Huang,
| | - Huafang Li
- *Correspondence: Huafang Li, ; Yifeng Shen, ; Jingjing Huang,
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Abstract
Clozapine is the only antipsychotic with proven effectiveness in treatment-resistant schizophrenia. It is usually administered using commercially available oral tablets, but not all patients are willing or able to take medicines in this way. Orodispersible clozapine tablets are available from several manufacturers and may be useful where swallowing solid dosage forms is difficult, or as an aid to observe compliance. Liquid formulations of clozapine can be prepared extemporaneously or purchased commercially, but most preparations are suspensions (clozapine is poorly soluble) and patients may find them unpalatable. The administration of clozapine (suspension or crushed tablets) via enteral feeding tubes (predominantly nasogastric) has been reported both in medically unwell patients and in patients refusing clozapine. Enteral administration is likely to be superseded by intramuscular clozapine, which has recently been re-introduced and is being widely used in some countries. Successful use of this formulation in enforced treatment strategies has been described by several authors with good long-term outcomes when switched to oral treatment. Intramuscular clozapine has also been used in physically ill patients who are unable to take any form of enteral medication. Other methods of delivery (transdermal, nasal) are not yet commercially available, but offer promise of further treatment options for this group of seriously ill patients.
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Affiliation(s)
- Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Li XQ, Tang XR, Li LL. Antipsychotics cardiotoxicity: What's known and what's next. World J Psychiatry 2021; 11:736-753. [PMID: 34733639 PMCID: PMC8546771 DOI: 10.5498/wjp.v11.i10.736] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/08/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic use of antipsychotic medications entails a dilemma between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. Antipsychotic-induced cardiotoxicity is one of the most life-threatening adverse effects that raises widespread concerns. These cardiotoxic effects range from arrhythmia to heart failure in the clinic, with myocarditis/cardiomyopathy, ischemic injuries, and unexplained cardiac lesions as the pathological bases. Multiple mechanisms have been proposed to underlie antipsychotic cardiotoxicity. This review aims to summarize the clinical signs and pathological changes of antipsychotic cardiotoxicity and introduce recent progress in understanding the underlying mechanisms at both the subcellular organelle level and the molecular level. We also provide an up-to-date perspective on future clinical monitoring and therapeutic strategies for antipsychotic cardiotoxicity. We propose that third-generation antipsychotics or drug adjuvant therapy, such as cannabinoid receptor modulators that confer dual benefits — i.e., alleviating cardiotoxicity and improving metabolic disorders — deserve further clinical evaluation and marketing.
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Affiliation(s)
- Xiao-Qing Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Xin-Ru Tang
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
| | - Li-Liang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai 200032, China
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Abstract
Clozapine is the most effective antipsychotic for patients with treatment-refractory schizophrenia, but many refuse to accept oral clozapine therapy. Intramuscular (IM) clozapine represents a convenient alternative for their treatment. The aim of this review is to summarize studies investigating IM clozapine administration. When initially developed, clozapine was also provided as an IM formulation, but the manufacturer later discontinued its production. Recently, IM clozapine became again available as an unlicensed product distributed by the Dutch company Apotheek A15. The use of IM clozapine has been reported in older studies on clozapine's adverse effects. It has also been described in detail in 5 more recent and generally smaller (n = 7 - 59) retrospective studies in patients refusing to take oral clozapine. In addition, its administration has been noted in 5 case reports. IM clozapine has been used at approximately ½ of the dose of oral clozapine due to pharmacokinetic considerations. It has been used in doses of up to 500 mg per day and for up to 99 days of treatment. The majority of patients (between 60 and 100%) were successfully transitioned to oral clozapine within a few days of IM treatment, and improvement in their condition was sustained during the long-term follow-up. Side effects of IM clozapine were similar to those of oral clozapine, but its sedative and cardiovascular effects (hypotension and tachycardia) had faster onset following IM administration. After long-term use, clozapine injections lead to local swelling and to the formation of painful nodules in some patients. In summary, IM clozapine may facilitate successful transition to oral clozapine in most patients, and it definitely represents a valuable tool for addressing refusal of oral clozapine in patients with treatment-refractory schizophrenia. More studies, especially focused on its safety, are, however, needed to better understand the limitations of this novel treatment approach.
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Affiliation(s)
- Benedikt Munzar
- Department of Psychiatry, Ben-Gurion University of the Negev, Beer Sheva, ISR
| | - Boris Nemets
- Department of Psychiatry, Ben-Gurion University of the Negev, Beer Sheva, ISR
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