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Wagner E, Siafis S, Fernando P, Falkai P, Honer WG, Röh A, Siskind D, Leucht S, Hasan A. Efficacy and safety of clozapine in psychotic disorders-a systematic quantitative meta-review. Transl Psychiatry 2021; 11:487. [PMID: 34552059 PMCID: PMC8458455 DOI: 10.1038/s41398-021-01613-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023] Open
Abstract
A recent increase in the literature regarding the evidence base for clozapine has made it increasingly difficult for clinicians to judge "best evidence" for clozapine use. As such, we aimed at elucidating the state-of-the-art for clozapine with regard to efficacy, effectiveness, tolerability, and management of clozapine and clozapine-related adverse events in neuropsychiatric disorders. We conducted a systematic PRISMA-conforming quantitative meta-review of available meta-analytic evidence regarding clozapine use. Primary outcome effect sizes were extracted and transformed into relative risk ratios (RR) and standardized mean differences (SMD). The methodological quality of meta-analyses was assessed using the AMSTAR-2 checklist. Of the 112 meta-analyses included in our review, 61 (54.5%) had an overall high methodological quality according to AMSTAR-2. Clozapine appears to have superior effects on positive, negative, and overall symptoms and relapse rates in schizophrenia (treatment-resistant and non-treatment-resistant subpopulations) compared to first-generation antipsychotics (FGAs) and to pooled FGAs/second-generation antipsychotics (SGAs) in treatment-resistant schizophrenia (TRS). Despite an unfavorable metabolic and hematological adverse-event profile compared to other antipsychotics, hospitalization, mortality and all-cause discontinuation (ACD) rates of clozapine surprisingly show a pattern of superiority. Our meta-review outlines the superior overall efficacy of clozapine compared to FGAs and most other SGAs in schizophrenia and suggests beneficial efficacy outcomes in bipolar disorder and Parkinson's disease psychosis (PDP). More clinical studies and subsequent meta-analyses are needed beyond the application of clozapine in schizophrenia-spectrum disorders and future studies should be directed into multidimensional clozapine side-effect management to foster evidence and to inform future guidelines.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Spyridon Siafis
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Piyumi Fernando
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Peter Falkai
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - William G. Honer
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Astrid Röh
- grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Dan Siskind
- grid.1003.20000 0000 9320 7537School of Medicine, University of Queensland, Brisbane, Australia ,Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Stefan Leucht
- grid.15474.330000 0004 0477 2438Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Alkomiet Hasan
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany ,grid.7307.30000 0001 2108 9006Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Medical Faculty, University of Augsburg, Augsburg, Germany
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Okhuijsen‐Pfeifer C, Huijsman EAH, Hasan A, Sommer IEC, Leucht S, Kahn RS, Luykx JJ. Clozapine as a first- or second-line treatment in schizophrenia: a systematic review and meta-analysis. Acta Psychiatr Scand 2018; 138:281-288. [PMID: 30218445 PMCID: PMC6175356 DOI: 10.1111/acps.12954] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2018] [Indexed: 12/02/2022]
Abstract
OBJECTIVE No consensus exists on whether clozapine should be prescribed in early stages of psychosis. This systematic review and meta-analysis therefore focus on the use of clozapine as first-line or second-line treatment in non-treatment-resistant patients. METHODS Articles were eligible if they investigated clozapine compared to another antipsychotic as a first- or second-line treatment in non-treatment-resistant schizophrenia spectrum disorders (SCZ) patients and provided data on treatment response. We performed random-effects meta-analyses. RESULTS Fifteen articles were eligible for the systematic review (N = 314 subjects on clozapine and N = 800 on other antipsychotics). Our meta-analysis comparing clozapine to a miscellaneous group of antipsychotics revealed a significant benefit of clozapine (Hedges' g = 0.220, P = 0.026, 95% CI = 0.026-0.414), with no evidence of heterogeneity. In addition, a sensitivity analysis revealed a significant benefit of clozapine over risperidone (Hedges' g = 0.274, P = 0.030, 95% CI = 0.027-0.521). CONCLUSION The few eligible trials on this topic suggest that clozapine may be more effective than other antipsychotics when used as first- or second-line treatment. Only large clinical trials may comprehensively probe disease stage-dependent superiority of clozapine and investigate overall tolerability.
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Affiliation(s)
- C. Okhuijsen‐Pfeifer
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - E. A. H. Huijsman
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - A. Hasan
- Department of Psychiatry and PsychotherapyKlinikum der UniversitätMunichGermany
| | - I. E. C. Sommer
- Department of Neuroscience and Department of PsychiatryUniversitair Medisch Centrum GroningenGroningenThe Netherlands
| | - S. Leucht
- Department of Psychiatry and PsychotherapyTechnische Universität MünchenMunichGermany
| | - R. S. Kahn
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of PsychiatryIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - J. J. Luykx
- Department of PsychiatryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of Translational NeuroscienceBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands,Department of PsychiatryZNA HospitalsAntwerpBelgium,Department of PsychiatrySymforaMeander HospitalAmersfoortThe Netherlands
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Moeller S, Kalkwarf N, Lücke C, Ortiz D, Jahn S, Först C, Braun N, Philipsen A, Müller HH. Achieving stable remission with maintenance electroconvulsive therapy in a patient with treatment-resistant schizophrenia: A case report. Medicine (Baltimore) 2017; 96:e8813. [PMID: 29310360 PMCID: PMC5728761 DOI: 10.1097/md.0000000000008813] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Up to one third of all schizophrenic patients are classified as having treatment-resistant schizophrenia (TRS). This subgroup faces remarkable medical and psychosocial damages, and pharmacotherapy is often limited due to nonresponse and/or side effects. Maintenance electroconvulsive therapy (M-ECT) might be effective in TRS. PATIENT CONCERNS We present a case of a 26-year-old male patient with a TRS. DIAGNOSES He received a treatment series of ECT sessions and a course of 24 M-ECTs. INTERVENTIONS The entire treatment was tolerated without significant side effects. OUTCOMES Moreover, the Psychotic Symptom Rating Scale (PSYRATS) scores for both positive and negative symptoms decreased and remained stable over the course of M-ECT. LESSONS Because of the remarkable improvement in the negative and positive symptom clusters, we propose systematic examinations in the field of M-ECT in TRS patients. These studies should integrate long-term outcome and tolerance measurements, gaining insight into the optimal duration of treatment for this indication.
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Affiliation(s)
- Sebastian Moeller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Neele Kalkwarf
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Caroline Lücke
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Diana Ortiz
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Sonja Jahn
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Christiane Först
- Geriatric Psychiatry
- ECT Unit, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Niclas Braun
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Alexandra Philipsen
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Helge H.O. Müller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
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Dalgard CL, Jacobowitz DM, Singh VK, Saleem KS, Ursano RJ, Starr JM, Pollard HB. A novel analytical brain block tool to enable functional annotation of discriminatory transcript biomarkers among discrete regions of the fronto-limbic circuit in primate brain. Brain Res 2015; 1600:42-58. [DOI: 10.1016/j.brainres.2014.12.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 12/07/2014] [Accepted: 12/11/2014] [Indexed: 01/05/2023]
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