Reintroduction of Clozapine After Perforation of the Large Intestine—A Case Report and Review of the Literature

Efficacy of clozapine versus standard treatment in adult individuals with intellectual disability and treatment-resistant psychosis (CLOZAID): study protocol of a multicenter randomized clinical trial

Background

Intellectual disability (ID) affects approximately 1% of the worldwide population and individuals with ID have a higher comorbidity with mental illness, and specifically psychotic disorders. Unfortunately, among individuals with ID, limited research has been conducted since ID individuals are usually excluded from mental illness epidemiological studies and clinical trials. Here we perform a clinical trial to investigate the effectiveness of clozapine in the treatment of resistant psychosis in individuals with ID. The article highlights the complexity of diagnosing and treating psychopathological alterations associated with ID and advocates for more rigorous research in this field.

Methods

A Phase IIB, open-label, randomized, multicenter clinical trial (NCT04529226) is currently ongoing to assess the efficacy of oral clozapine in individuals diagnosed with ID and suffering from treatment-resistant psychosis. We aim to recruit one-hundred and fourteen individuals (N=114) with ID and resistant psychosis, who will be randomized to TAU (treatment as usual) and treatment-with-clozapine conditions. As secondary outcomes, changes in other clinical scales (PANSS and SANS) and the improvement in functionality, assessed through changes in the Euro-QoL-5D-5L were assessed. The main outcome variables will be analyzed using generalized linear mixed models (GLMM), assessing the effects of status variable (TAU vs. Clozapine), time, and the interaction between them.

Discussion

The treatment of resistant psychosis among ID individuals must be directed by empirically supported research. CLOZAID clinical trial may provide relevant information about clinical guidelines to optimally treat adults with ID and treatment-resistant psychosis and the benefits and risks of an early use of clozapine in this underrepresented population in clinical trials.

Trial registration

Clinicaltrials.gov: NCT04529226. EudraCT: 2020-000091-37.

Recognition and management of clozapine adverse effects: A systematic review and qualitative synthesis

OBJECTIVE

Clozapine is substantially underutilized in most countries and clinician factors including lack of knowledge and concerns about adverse drug effects (ADEs) contribute strongly to treatment reluctance. The aim of this systematic review was to provide clinicians with a comprehensive information source regarding clozapine ADEs.

METHODS

PubMed and Embase databases were searched for English language reviews concerned with clozapine ADEs; publications identified by the automated search were manually searched for additional relevant citations. Following exclusion of redundant and irrelevant reports, pertinent information was summarized in evidence tables corresponding to each of six major ADE domains; two authors reviewed all citations for each ADE domain and summarized their content by consensus in the corresponding evidence table. This study was conducted in accordance with PRISMA principles.

RESULTS

Primary and secondary searches identified a total of 305 unique reports, of which 152 were included in the qualitative synthesis. Most clozapine ADEs emerge within 3 months, and almost all appear within 6 months, after initiation. Notable exceptions are weight gain, diabetic ketoacidosis (DKA), severe clozapine-induced gastrointestinal hypomotility (CIGH), clozapine-induced cardiomyopathy (CICM), seizures, and clozapine-induced neutropenia (CIN). Most clozapine ADEs subside gradually or respond to dose reduction; those that prompt discontinuation generally do not preclude rechallenge. Rechallenge is generally inadvisable for clozapine-induced myocarditis (CIM), CICM, and clozapine-induced agranulocytosis (CIA). Clozapine plasma levels >600-1000 μg/L appear more likely to cause certain ADEs (e.g., seizures) and, although there is no clear toxicity threshold, risk/benefit ratios are generally unfavorable above 1000 μg/L.

CONCLUSION

Clozapine ADEs rarely require discontinuation.

Clozapine-Induced Constipation: A Case Report and Review of Current Management Guidelines

Clozapine is a second-generation antipsychotic recommended after the failure of two or more antipsychotics for treatment-resistant schizophrenia. Clozapine proved to also decrease recurrent suicidal behaviors in schizophrenia spectrum disorders. Yet, physicians often use clozapine as a last resort despite its proven efficacy due to its side effect profile. A noted side effect of clozapine is agranulocytosis, which requires a weekly complete blood count with differentials. Clozapine's anticholinergic activity causes colonic hypomotility, leading to constipation, and only a few studies examined clozapine-induced constipation (CIC). Few of the reported complications of CIC include bowel obstruction or bowel perforation due to fecal impaction. Herein we document a case report of CIC and also conducted a review of published case reports examining the complexity and management of CIC. CIC is a critical condition if unresolved as it can lead to mortality. Future directions and guidelines should be developed for early diagnosis and treatment for CIC, which will provide reassurance and directions for both the physicians and patients.

Clozapine: why wait to start a laxative?

Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.

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Multiple spontaneous small bowel perforations due to clozapine-Case report

INTRODUCTION

Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm. A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation.

CASE PRESENTATION

The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum. An emergency laparotomy revealed multiple jejunal and ileal perforations. The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess. Histologic specimens showed nonspecific inflammatory findings with ischemia. The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded.

DISCUSSION

Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine.

CONCLUSION

The cause was attributed to clozapine as the other etiologies were excluded. The clozapine's reintroduction is controversial. In this case the clozapine dose was reduced successfully.

Clozapine Rechallenge After Major Adverse Effects: Clinical Guidelines Based on 259 Cases

BACKGROUND

Clozapine is widely prescribed for treatment-refractory schizophrenia, but its use is limited by many potentially life-threatening adverse effects. The risk of rechallenge after these complications has never been comprehensively assessed in controlled studies. Thus, clinical guidelines must rely on the published case reports. The number of such reports is likely to increase over time, and updated analyses of larger samples are needed, as they may lead to changes in clinical guidelines.

STUDY QUESTIONS

How safe is the clozapine rechallenge after life-threatening adverse effects?

STUDY DESIGN

The published case reports of clozapine rechallenge were identified in a MEDLINE search. We added 121 cases reported from 2012 through 2017 to the 138 cases reported from 1972 through 2011 analyzed by us in a previous publication. The 95% confidence intervals (CIs) of the successful rechallenge rate were calculated for each adverse effect with at least 5 published case reports. The rechallenge was considered a valid clinical option when the lower end of the CI range was at least 50%.

RESULTS

A successful outcome was documented in 128/203 patients rechallenged after neutropenia (63.0%, CI, 56.0%-69.6%), 3/17 after agranulocytosis (17.7%, CI, 4.7%-44.2%), 11/17 after myocarditis (64.7%, CI, 38.6%-84.7%), and 7/7 after neuroleptic malignant syndrome (100%, CI, 56.1%-100%). Among the 15 patients with other clozapine-induced adverse effects, the rechallenge was successful in those with eosinophilia, cardiac complications other than myocarditis (QTc prolongation, pericarditis, cardiomyopathy, and atrial flutter), and gastrointestinal hypomotility. The rechallenge failed in patients who had developed pancreatitis or renal insufficiency.

CONCLUSION

Clozapine rechallenge is a reasonable clinical option after return to baseline for patients who had developed neutropenia and neuroleptic malignant syndrome, but not after agranulocytosis or myocarditis. Data are insufficient to formulate rechallenge guidelines for any other clozapine-related adverse effects.

Clozapine in Reducing Aggression and Violence in Forensic Populations

Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.