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Bleich L, Grohmann R, Greil W, Dabbert D, Erfurth A, Toto S, Seifert J. Clozapine-associated adverse drug reactions in 38,349 psychiatric inpatients: drug surveillance data from the AMSP project between 1993 and 2016. J Neural Transm (Vienna) 2024; 131:1117-1134. [PMID: 39136776 PMCID: PMC11365862 DOI: 10.1007/s00702-024-02818-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/31/2024] [Indexed: 09/02/2024]
Abstract
Clozapine is a second-generation antipsychotic drug that offers superior treatment results in patients with schizophrenia but is also associated with significant risks. This study analyzes data on pharmacotherapy with clozapine and the associated adverse drug reactions (ADRs) in an inpatient setting including 38,349 patients. Data about the use of clozapine and reports of severe ADRs within the period 1993-2016 were obtained from the multicentered observational pharmacovigilance program "Arzneimittelsicherheit in der Psychiatrie" (AMSP). In total, 586 severe clozapine-associated ADRs were documented (1.53% of all patients exposed). Patients aged ≥65 years had a higher risk of ADRs than patients aged <65 years (1.96 vs. 1.48%; p = 0.021). Significantly more ADRs were attributed to clozapine alone (396; 67.6% of all 586 ADRs) than to a combination with other drugs. The most frequent ADRs were grand mal seizures (0.183% of all 38,349 patients exposed), delirium (0.180%), increased liver enzymes (0.120%), and agranulocytosis (0.107%). We detected 24 cases (0.063%) of clozapine-induced extrapyramidal symptoms, of which 8 (0.021%) were attributed to clozapine alone. Five ADRs resulted in death (0.013%): 2 due to agranulocytosis (41 cases total) (mortality = 4.88%) and 3 due to paralytic (sub)ileus (16 cases) (mortality = 18.75%). The median dose of clozapine in all patients treated was 300 mg/day, in patients who developed ADRs 250 mg/day. The main risk factor for an ADR was pre-existing damage of the affected organ system. Overall, the results of this study highlight the importance of alertness-especially of frequently overlooked symptoms-and appropriate monitoring during treatment with clozapine, even at low doses.
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Affiliation(s)
- Lene Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany.
- University Medical Center Göttingen, 37075, Göttingen, Germany.
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, LMU University Hospital, 80336, Munich, Germany
| | - Waldemar Greil
- Department of Psychiatry and Psychotherapy, LMU University Hospital, 80336, Munich, Germany
- Psychiatric Private Hospital, Sanatorium Kilchberg, 8802, Kilchberg, Switzerland
| | - Dominik Dabbert
- Department of Forensic Psychiatry and Psychotherapy, Klinik Bremen-Ost, 28325, Bremen, Germany
| | - Andreas Erfurth
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Klinik Hietzing, 1130, Vienna, Austria
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, 30625, Hannover, Germany
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Theron CW, Salcedo-Sora JE, Grixti JM, Møller-Hansen I, Borodina I, Kell DB. Evidence for the Role of the Mitochondrial ABC Transporter MDL1 in the Uptake of Clozapine and Related Molecules into the Yeast Saccharomyces cerevisiae. Pharmaceuticals (Basel) 2024; 17:938. [PMID: 39065789 PMCID: PMC11279418 DOI: 10.3390/ph17070938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/25/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Clozapine is an antipsychotic drug whose accumulation in white cells can sometimes prove toxic; understanding the transporters and alleles responsible is thus highly desirable. We used a strategy in which a yeast (Saccharomyces cerevisiae) CRISPR-Cas9 knock-out library was exposed to cytotoxic concentrations of clozapine to determine those transporters whose absence made it more resistant; we also recognised the structural similarity of the fluorescent dye safranin O (also known as safranin T) to clozapine, allowing it to be used as a surrogate marker. Strains lacking the mitochondrial ABC transporter MDL1 (encoded by YLR188W) showed substantial resistance to clozapine. MDL1 overexpression also conferred extra sensitivity to clozapine and admitted a massive increase in the cellular and mitochondrial uptake of safranin O, as determined using flow cytometry and microscopically. Yeast lacking mitochondria showed no such unusual accumulation. Mitochondrial MDL1 is thus the main means of accumulation of clozapine in S. cerevisiae. The closest human homologue of S. cerevisiae MDL1 is ABCB10.
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Affiliation(s)
- Chrispian W. Theron
- GeneMill Biofoundry, Liverpool Shared Research Facilities, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK;
| | - J. Enrique Salcedo-Sora
- GeneMill Biofoundry, Liverpool Shared Research Facilities, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK;
| | - Justine M. Grixti
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrated Biology, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK
| | - Iben Møller-Hansen
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Søltofts Plads 220, 2800 Kongens Lyngby, Denmark
| | - Irina Borodina
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Søltofts Plads 220, 2800 Kongens Lyngby, Denmark
| | - Douglas B. Kell
- GeneMill Biofoundry, Liverpool Shared Research Facilities, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK;
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrated Biology, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Søltofts Plads 220, 2800 Kongens Lyngby, Denmark
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Mutlu E, Özçelik Eroğlu E, Coşkun FÖ, Koçyiğit D, Canpolat İKN, Avcı H, Ertuğrul A, Anıl Yağcıoğlu AE. A systematic chart review of pharmacological interventions in patients with clozapine-induced hypersalivation. Schizophr Res 2024; 268:138-144. [PMID: 37597972 DOI: 10.1016/j.schres.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES To investigate the efficacy and tolerability of medications, such as mouthwash use of 1 % atropine sulfate and tropicamide drops, oral amitriptyline and amisulpride used for clozapine-induced hypersalivation (CIH). METHODS The medical charts of inpatients with psychotic disorders between 2010 and 2022 were reviewed retrospectively. We detected 161 patients with eligible data who received or commenced clozapine. Primary outcome was defined as the percentage change in the diameter of a wet patch on the pillow (DWP) for improvements in CIH. RESULTS The frequency of CIH was 42 % (n = 68). The first step medications for CIH were tropicamide drops (49 %), atropine drops (43 %) and amitriptyline (3 %). After the first step, the median DWP significantly decreased by -33 %. During the index hospitalization, in 18 patients with persistent CIH, the median DWP significantly decreased by -42 % with the second step medications which also included amisulpride. There were no reported serious adverse events. The change in DWP was significantly correlated with the duration of clozapine treatment (r = 306) and clozapine serum level at discharge (r = 0.294). A linear regression model showed a link between the change in DWP and reduced Positive and Negative Syndrome Scale scores. CONCLUSIONS Our findings emphasize that mouthwash use of atropine or tropicamide drops has a satisfying and tolerable effect in treating CIH. Switching medications for CIH seems to be effective when CIH persists despite a first step agent. Controlled follow-up studies are needed to understand the relationship between CIH, clozapine serum levels, illness severity, and functioning.
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Affiliation(s)
- Emre Mutlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - Elçin Özçelik Eroğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - F Özlem Coşkun
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Doğukan Koçyiğit
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - İrem K N Canpolat
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Hanife Avcı
- Department of Biostatistics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - A Elif Anıl Yağcıoğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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De Las Cuevas C, Sanz EJ, de Leon J. Adverse drug reactions and their fatal outcomes in clozapine patients in VigiBase: Comparing the top four reporting countries (US, UK, Canada and Australia). Schizophr Res 2024; 268:165-174. [PMID: 37301669 DOI: 10.1016/j.schres.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Pharmacovigilance findings and box warnings in the clozapine package inserts have marked the history of clozapine. OBJECTIVE This is the largest review of clozapine adverse drug reactions (ADRs) and their associated fatal outcomes. Reports to the World Health Organization's global pharmacovigilance database, VigiBase™, were analyzed, extending from clozapine's introduction to December 31, 2022. METHODS The analysis focused on the top four reporting countries: United States (US), United Kingdom (UK), Canada and Australia (83 % of fatal outcomes worldwide). Attempts were made to control for population and clozapine prescription in each country. RESULTS Clozapine ADRs worldwide accounted for 191,557 reports, with the highest number (53,505) in "blood and lymphatic system disorder". Of the 22,596 fatal outcomes reported in clozapine patients, 9587 were from the US, 6567 from the UK, 3623 from Canada and 1484 from Australia. The top category worldwide in fatal outcomes was nonspecifically labeled "death" with 46 % (range 22-62 %). "Pneumonia" was second with 30 % (range 17-45 %). Agranulocytosis was numerically only the 35th top clozapine ADR associated with fatal outcomes. On average, 2.3 clozapine ADRs were reported per fatal outcome. Infections were associated with 24.2 % of the UK fatal outcomes (9.4 %-11.9 % in the 3 other countries). CONCLUSIONS The four countries appeared to report clozapine ADRs in different ways, making comparisons difficult. We estimated higher fatal outcomes in the UK and Canada after controlling for cross-sectional estimations of population and published clozapine use. This last hypothesis is limited by the lack of precise estimation of accumulated clozapine use in each country.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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Verdoux H, Quiles C, de Leon J. Optimizing co-prescription of clozapine and antiseizure medications: a systematic review and expert recommendations for clinical practice. Expert Opin Drug Metab Toxicol 2024; 20:347-358. [PMID: 38613254 DOI: 10.1080/17425255.2024.2343020] [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: 01/15/2024] [Accepted: 04/10/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Antiseizure medication (ASM) add-on to clozapine may be efficient to target clozapine-resistant mood or psychotic symptoms or clozapine-related adverse drug reactions (ADR) such as seizures. We aimed to synthesize the information relevant for clinical practice on the risks and benefits of clozapine-ASM co-prescription. AREAS COVERED Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through October 2023. The review was restricted to ASM with mood-stabilizing properties or with potential efficacy for resistant psychotic symptoms (valproate (VPA), lamotrigine, topiramate, carbamazepine, oxcarbazepine). EXPERT OPINION VPA add-on to clozapine is associated with a high risk of serious ADR (myocarditis, neutropenia, pneumonia) mostly explained by complex time-dependent drug-drug interactions. The initial inhibitory effects on clozapine metabolism require slow titration to avoid immuno-allergic reactions. After the titration period, VPA has mainly inductive effects on clozapine metabolism that are more marked in smokers requiring therapeutic drug monitoring. Lamotrigine and topiramate add-on may be recommended as the first-line treatment for clozapine-related seizures, but there is limited evidence regarding the efficacy of this strategy for clozapine-resistant psychotic symptoms. Carbamazepine should not be co-prescribed with clozapine because of its potential for agranulocytosis and for inducing clozapine metabolism.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, Bordeaux, France
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Wiss FM, Allemann SS, Meyer zu Schwabedissen HE, Stäuble CK, Mikoteit T, Lampert ML. Recurrent high creatine kinase levels under clozapine treatment - a case report assessing a suspected adverse drug reaction. Front Psychiatry 2024; 15:1397876. [PMID: 38742124 PMCID: PMC11089194 DOI: 10.3389/fpsyt.2024.1397876] [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: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 05/16/2024] Open
Abstract
Suspected adverse drug reactions (ADRs) during treatment with clozapine often prompt therapeutic drug monitoring (TDM) in clinical practice. Currently, there is no official recommendation for pharmacogenetic (PGx) testing in the context of clozapine therapy. In this case report, we demonstrate and discuss the challenges of interpreting PGx and TDM results highlighting the possibilities and limitations of both analytical methods. A 36-year-old male patient with catatonic schizophrenia was treated with clozapine. He experienced multiple hospitalizations due to elevated creatine kinase (CK) levels (up to 9000 U/L, reference range: 30-200 U/L). With no other medical explanation found, physicians suspected clozapine-induced ADRs. However, plasma levels of clozapine were consistently low or subtherapeutic upon admission, prompting us to conduct a PGx analysis and retrospectively review the patient's TDM data, progress notes, and discharge reports. We investigated two possible hypotheses to explain the symptoms despite low clozapine plasma levels: Hypothesis i. suggested the formation and accumulation of a reactive intermediate metabolite due to increased activity in cytochrome P450 3A5 and reduced activity in glutathione S-transferases 1, leading to myotoxicity. Hypothesis ii. proposed under-treatment with clozapine, resulting in ineffective clozapine levels, leading to a rebound effect with increased catatonic symptoms and CK levels. After considering both data sources (PGx and TDM), hypothesis ii. appeared more plausible. By comprehensively assessing all available TDM measurements and examining them in temporal correlation with the drug dose and clinical symptoms, we observed that CK levels normalized when clozapine plasma levels were raised to the therapeutic range. This was achieved through hospitalization and closely monitored clozapine intake. Therefore, we concluded that the symptoms were not an ADR due to altered clozapine metabolism but rather the result of under-treatment. Interpreting TDM and PGx results requires caution. Relying solely on isolated PGx or single TDM values can result in misinterpretation of drug reactions. We recommend considering the comprehensive patient history, including treatment, dosages, laboratory values, clinic visits, and medication adherence.
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Affiliation(s)
- Florine M. Wiss
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, Olten, Switzerland
| | - Samuel S. Allemann
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Céline K. Stäuble
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, Olten, Switzerland
- Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Thorsten Mikoteit
- Psychiatric Services Solothurn, Solothurner Spitäler and Department of Medicine, University of Basel, Solothurn, Switzerland
| | - Markus L. Lampert
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, Olten, Switzerland
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Lam EWF, Ip BPI. The prevalence of constipation in adult psychiatric out-patients on clozapine treatment at a regional public hospital in Hong Kong. Hum Psychopharmacol 2024:e2897. [PMID: 38605548 DOI: 10.1002/hup.2897] [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: 01/16/2024] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To determine the occurrence of constipation in local patients on clozapine treatment, and to compare the demographical and clinical characteristics of patients on clozapine treatment with or without constipation. METHODS This is a cross-sectional, observational study. All adult psychiatric out-patients on clozapine treatment attending follow-up at a regional hospital were recruited for clinical interview and medical record review. The Enhanced Asian Rome III Questionnaire (EAR3Q) was used to define patients with constipation. The Bristol Stool Form Scale (BSFS) was used to assess stool form. The Brief Psychiatric Rating Scale-Anchored (BPRS-A) was used to measure psychiatric symptoms. The Brief Medication Adherence Scale (BMAS) was used to assess treatment adherence. Logistic regression was conducted to identify independent associating factors of constipation in patients on clozapine treatment. RESULTS The prevalence of constipation in patients on clozapine treatment was 26.3%, (95% CI [21.5%, 31.6%]). Independent associating factors included disorder of psychological development (aOR = 6.98, 95% CI [1.24, 39.18]), anxiety (very mild: aOR = 9.23, 95% CI [2.59, 32.87]; mild: aOR = 2.66, 95% CI [1.26, 5.62]), prescription with combination of laxatives (aOR = 0.40, 95% CI [0.17, 0.95]), and concomitant use of amisulpride (aOR = 2.52, 95% CI [1.09, 5.82]), quetiapine (aOR = 5.92, 95% CI [1.11, 31.56]) and metamucil (aOR = 9.30, 95% CI [1.53, 56.58]). CONCLUSION This study examined the prevalence of clozapine-associated constipation in Hong Kong using a validated questionnaire. The identification of independent factors associated with constipation could facilitate better risk stratification and risk modification in clinical practice.
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Affiliation(s)
- Eric Wai-Fung Lam
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Brian Pak-In Ip
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
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Ding J, Liu J, Zhang Y, Xing H, Zhang Y, Li L, Zhang S, Wang H, Yang L, Cui X. A retrospective study of clozapine and norclozapine concentration in patients with schizophrenia: Data from the Therapeutic Drug Monitoring Service, 2019-2022. Asian J Psychiatr 2024; 91:103865. [PMID: 38113699 DOI: 10.1016/j.ajp.2023.103865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim of this research was to assess the therapeutic drug monitoring (TDM) of clozapine (CLO) and norclozapine (NCLO). METHODS TDM results of CLO and NCLO in patients obtained from the Xi'an Mental Health Center were retrospectively analyzed. RESULTS TDM of CLO and NCLO was typically conducted only once in the majority of patients, particularly those receiving outpatient care. The CLO plasma concentrations were higher in inpatients and female patients. The interquartile (25th-75th) CLO concentrations ranged from 129.83 to 397.53 ng/mL, nearly 68.63% of the samples had subtherapeutic concentrations (<350 ng/mL). Receiver operating characteristic curve analysis showed that inpatients achieved the therapeutic level concentration of 350-600 ng/mL when their daily CLO dose was > 125 mg. CONCLUSIONS It was surprising to find such a large number of patients with CLO levels below the therapeutic range, there is still a window of improvement for optimizing pharmacological treatments in clinical practice.
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Affiliation(s)
- Jing Ding
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Jianfeng Liu
- Department of Psychiatry, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Yan Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Huan Xing
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Yang Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Luyao Li
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Suo Zhang
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Huiyuan Wang
- Department of Psychiatry, Xi'an Mental Health Center, 710100 Xi'an, PR China
| | - Liu Yang
- Department of Research and Education, Xi'an Mental Health Center, 710100 Xi'an, PR China.
| | - Xiaohua Cui
- Xi'an Mental Health Center, 710100 Xi'an, PR China; Xi'an Key Laboratory of Pharmacy (Mental Health), Xi'an Mental Health Center, 710100 Xi'an, PR China; Pharmacy Laboratory, Xi'an Mental Health Center, 710100 Xi'an, PR China.
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Krejčí V, Murínová I, Slanař O, Šíma M. Evidence for Therapeutic Drug Monitoring of Atypical Antipsychotics. Prague Med Rep 2024; 125:101-129. [PMID: 38761044 DOI: 10.14712/23362936.2024.10] [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: 05/20/2024] Open
Abstract
Second-generation antipsychotics (SGAs), also known as atypical antipsychotics, are a newer class of antipsychotic drugs used to treat schizophrenia, bipolar disorder, and related psychiatric conditions. The plasma concentration of antipsychotic drugs is a valid measure of the drug at its primary target structure in the brain, and therefore determines the efficacy and safety of these drugs. However, despite the well-known high variability in pharmacokinetics of these substances, psychiatric medication is usually administered in uniform dosage schedules. Therapeutic drug monitoring (TDM), as the specific method that can help personalised medicine in dose adjustment according to the characteristics of the individual patient, minimizing the risk of toxicity, monitoring adherence, and increasing cost-effectiveness in the treatment, thus seems to be an elegant tool to solve this problem. Non-response to therapeutic doses, uncertain adherence to medication, suboptimal tolerability, or pharmacokinetic drug-drug interactions are typical indications for TDM of SGAs. This review aims to summarize an overview of the current knowledge and evidence of the possibilities to tailor the dosage of selected SGAs using TDM, including the necessary pharmacokinetic parameters for personalised pharmacotherapy.
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Affiliation(s)
- Veronika Krejčí
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czech Republic.
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Irena Murínová
- Department of Applied Pharmacy, Faculty of Pharmacy, Masaryk University, Brno, Czech Republic
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Šíma
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Lock SK, Legge SE, Kappel DB, Willcocks IR, Helthuis M, Jansen J, Walters JTR, Owen MJ, O'Donovan MC, Pardiñas AF. Mediation and longitudinal analysis to interpret the association between clozapine pharmacokinetics, pharmacogenomics, and absolute neutrophil count. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:74. [PMID: 37853043 PMCID: PMC10585000 DOI: 10.1038/s41537-023-00404-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
Clozapine is effective at reducing symptoms of treatment-resistant schizophrenia, but it can also induce several adverse outcomes including neutropenia and agranulocytosis. We used linear mixed-effect models and structural equation modelling to determine whether pharmacokinetic and genetic variables influence absolute neutrophil count in a longitudinal UK-based sample of clozapine users not currently experiencing neutropenia (N = 811). Increased daily clozapine dose was associated with elevated neutrophil count, amounting to a 133 cells/mm3 rise per standard deviation increase in clozapine dose. One-third of the total effect of clozapine dose was mediated by plasma clozapine and norclozapine levels, which themselves demonstrated opposing, independent associations with absolute neutrophil count. Finally, CYP1A2 pharmacogenomic activity score was associated with absolute neutrophil count, supporting lower neutrophil levels in CYP1A2 poor metabolisers during clozapine use. This information may facilitate identifying at-risk patients and then introducing preventative interventions or individualised pharmacovigilance procedures to help mitigate these adverse haematological reactions.
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Affiliation(s)
- Siobhan K Lock
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Sophie E Legge
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Djenifer B Kappel
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Isabella R Willcocks
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | - John Jansen
- Leyden Delta B.V., Nijmegen, The Netherlands
| | - James T R Walters
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael J Owen
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Michael C O'Donovan
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Antonio F Pardiñas
- Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK.
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11
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Hatano M, Yamada K, Matsuzaki H, Yokoi R, Saito T, Yamada S. Analysis of clozapine-induced seizures using the Japanese Adverse Drug Event Report database. PLoS One 2023; 18:e0287122. [PMID: 37307250 DOI: 10.1371/journal.pone.0287122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
Among antipsychotics, clozapine is associated with a high risk of seizures. This study aimed to generate novel hypotheses regarding trends in the onset of clozapine-induced seizures using the JADER (Japanese Adverse Drug Event Report) database. Seizures were defined according to the Standardized MedDRA Queries (SMQ) for convulsions (SMQ20000079). Trends in the onset of clozapine-induced seizures were assessed using multivariate logistic regression analysis with covariates of sex, age, clozapine dose, antipsychotic polypharmacy, concomitant medications, and history of convulsive disorder. In addition, we assessed the time-to-onset of clozapine-induced seizures using the median time, interquartile range, and Weibull shape parameter. The JADER database registered 2,745 cases of adverse events with clozapine, and 1,784 cases were included in the analysis after excluding cases for which clinical information was not available. Medium (200-400 mg) and high (> 400 mg) doses of clozapine had a significantly higher reporting rate of seizures than low doses (< 200 mg) (adjusted reporting odds ratio [aROR] = 3.05, 95% confidence interval [CI]: 1.86-4.99 and aROR = 9.81, 95% CI: 6.06-15.89, respectively). Younger age, antipsychotic polypharmacy, and concomitant use of lithium were also significantly associated with reports of seizures. The time-to-onset analysis of 222 cases of clozapine-induced seizures showed that the median time was 134 (interquartile range, 72-295) days. The 95% CI of the WSP β-value for clozapine-induced seizures included 1 and was classified as a random failure type. In conclusion, the results suggest that clozapine-induced seizures are dose-dependent adverse events that should be monitored with consideration of the effects of age and concomitant medications. Further epidemiological research is needed to strengthen and validate our hypotheses.
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Affiliation(s)
- Masakazu Hatano
- Department of Pharmacotherapeutics and informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Kaho Yamada
- Department of Pharmacotherapeutics and informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Haruna Matsuzaki
- Department of Pharmacotherapeutics and informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Rina Yokoi
- Department of Pharmacotherapeutics and informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Takeo Saito
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shigeki Yamada
- Department of Pharmacotherapeutics and informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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12
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Demirbugen Oz M, Ozdemir F, Tok KC, Dural E, Kir Y, Ulusoy M, Gumustas M, Baskak B, Suzen HS. The potential role of por*28 and cyp1a2*f genetic variations and lifestyle factors on clozapine and n-desmethyl clozapine plasma levels in schizophrenia patients. Expert Opin Drug Metab Toxicol 2023. [PMID: 37269349 DOI: 10.1080/17425255.2023.2221849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Despite its advantages over other antipsychotics, for treatment-resistant schizophrenia, clinical use of Clozapine (CLZ) is challenging by its narrow therapeutic index and potentially life-threatening dose-related adverse effects. RESEARCH DESIGN AND METHODS As the potential role in CLZ metabolism is assigned to CYP1A2 enzyme and consequently Cytochrome P450 oxidoreductase (POR) their genetic variations might help to determine CLZ levels in schizophrenia patients. For this purpose, 112 schizophrenia patients receiving CLZ were included in the current study. Plasma CLZ and N-desmethylclozapine (DCLZ) levels were analyzed by using HPLC and genetic variations were identified with the PCR-RFLP method. RESULTS The patients' CYP1A2 and POR genotypes seemed to not affect plasma CLZ and DCLZ levels whereas in the subgroup analysis, POR × 28 genotype significantly influenced simple and adjusted plasma CLZ and DLCZ levels concerning smoking habit and caffeine consumption. CONCLUSIONS The findings of the present study highlight the importance of both genetic and non-genetic factors (smoking and caffeine consumption) for the individualization of the CLZ treatment. In addition to that, it suggests that the added utility of not only the CLZ metabolizing enzymes but also POR, which is crucial for proper CYP activity, to guide CLZ dosing might be useful for clinical decision-making.
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Affiliation(s)
- Merve Demirbugen Oz
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Ankara University, Ankara, Turkey
| | - Fezile Ozdemir
- Dr Fazil Kucuk Faculty of Medicine, Eastern Mediterranean University, North, Cyprus, Turkey
| | - Kenan Can Tok
- Institute of Forensic Sciences, Department of Forensic Toxicology, Ankara University, Ankara, Turkey
| | - Emrah Dural
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Sivas Cumhuriyet University, Sivas, Turkey
| | - Yagmur Kir
- Bursa Acibadem Hospital, Department of Psychiatry, Bursa, Turkey
| | - Muge Ulusoy
- School of Medicine, Department of Psychiatry, Ankara University, Ankara, Turkey
| | - Mehmet Gumustas
- Institute of Forensic Sciences, Department of Forensic Toxicology, Ankara University, Ankara, Turkey
| | - Bora Baskak
- School of Medicine, Department of Psychiatry, Ankara University, Ankara, Turkey
| | - H Sinan Suzen
- Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Ankara University, Ankara, Turkey
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13
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Tralongo F, Konecki C, Feliu C, Kaladjian A, Djerada Z. Association Between Clozapine Plasma Concentrations and Treatment Response: A Systematic Review, Meta-analysis and Individual Participant Data Meta-analysis. Clin Pharmacokinet 2023; 62:807-818. [PMID: 37145296 DOI: 10.1007/s40262-023-01247-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Although therapeutic drug monitoring of clozapine is recommended, its optimisation is often adjusted only on the basis of dosage. The aim of this study was to assess the link between clozapine plasma concentrations and clinical response by a meta-analysis of published studies and by an individual participant data meta-analysis. METHODS We conducted a computerised search of bibliographic databases (EMBASE, PubMed, Clinical Trials, and Web of Science) to identify studies that assessed the relationship between clozapine serum or plasma concentrations and clinical efficacy. Using pooled data, we investigated the association between improvement of clinical outcome and clozapine or norclozapine plasma concentrations, the sum of clozapine and norclozapine plasma concentrations, and the coefficient of variation of clozapine plasma concentrations. Using available individual data, we assessed the relationship between clozapine plasma concentrations and clinical response (changes in the Brief Psychiatric Rating Scale score) and identified a threshold level for a favourable clinical response. RESULTS Fifteen studies satisfied inclusion criteria. Our meta-analysis showed that responders had clozapine plasma concentrations that were, on average, 117 ng/mL higher than non-responders. The patients with plasma clozapine concentrations above the thresholds identified in each study had a higher likelihood of responding (odds ratio = 2.94, p < 0.001). Norclozapine plasma concentrations were not associated with a clinical response. The meta-analysis of individual data supported this result and confirmed the link between clozapine concentrations and a change in the Brief Psychiatric Rating Scale score and/or the probability of clinical response. Finally, with the analysis of the coefficient of variation of clozapine plasma concentrations, we found that a greater inter-individual fluctuation in plasma concentrations was associated with a loss of clinical response. CONCLUSIONS Our work confirmed that, in contrast to clozapine doses, clozapine plasma concentrations were related to a favourable clinical response, with a mean difference between responders and non-responders of 117 ng/mL. A threshold for a treatment response of 407 ng/mL was determined, with a high discriminatory capacity, and a sensitivity and specificity of 71% and 89.1%, respectively.
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Affiliation(s)
- Federica Tralongo
- Department of Pharmacology, University of Reims Champagne-Ardenne, HERVI EA 3801, Reims University Hospital, Reims, France
- Department of Psychiatry, Marne Public Mental Health Institution, Reims University Hospital, Reims, France
| | - Céline Konecki
- Department of Pharmacology, University of Reims Champagne-Ardenne, HERVI EA 3801, Reims University Hospital, Reims, France
| | - Catherine Feliu
- Department of Pharmacology, University of Reims Champagne-Ardenne, HERVI EA 3801, Reims University Hospital, Reims, France
| | - Arthur Kaladjian
- Department of Psychiatry, Marne Public Mental Health Institution, Reims University Hospital, Reims, France
| | - Zoubir Djerada
- Department of Pharmacology, University of Reims Champagne-Ardenne, HERVI EA 3801, Reims University Hospital, Reims, France.
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14
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Jin Y, Tong J, Huang Y, Shi D, Zhu N, Zhu M, Liu M, Liu H, Sun X. Effectiveness of accelerated intermittent theta burst stimulation for social cognition and negative symptoms among individuals with schizophrenia: A randomized controlled trial. Psychiatry Res 2023; 320:115033. [PMID: 36603383 DOI: 10.1016/j.psychres.2022.115033] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Social cognitive and negative symptoms impairment may increase the risk of mental disability in individuals with schizophrenia. However, randomized controlled studies on the effectiveness of accelerated intermittent theta burst stimulation (iTBS) for social cognition and negative symptoms in individuals with schizophrenia are very limited. METHODS A total of 125 individuals with schizophrenia were recruited, 66 of whom were randomly divided into an active iTBS group (n=34) and sham iTBS group (n=32) by stratified sampling. Participants received either active iTBS or sham iTBS targeting the left dorsolateral prefrontal cortex (DLPFC) 20 sessions for 4 weeks under navigation. The Facial Emotion Recognition Test (FERT), Hinting Task (HT), and Positive and Negative Syndrome Scale (PANSS) were measured at baseline, 2 weeks, and 4 weeks. The trial protocol was registered with the Chinese Clinical Trial Registry (ChiCTR2100051984). RESULTS Sixty patients (90.90%) completed the intervention and the 4-week follow-up, including 29 women (43.94%) and 37 men (56.06%) with a mean (SD) age of 47.53 (10.17) years. The primary outcomes showed FERT scores (week 2; 0.27 [95% CI, 0.09 to 0.45]; P< .01; ES 0.14) (week 4; 0.63 [95% CI, 0.45 to 0.80]; P< .001; ES 0.47) and HT scores (week 2; 1.00 [95% CI, -0.02 to 1.98]; P< .05; ES 0.67) (week 4; 2.13 [95% CI, 1.21 to 3.06]; P< .001; ES 0.27) in the active iTBS group were significantly different from those in the sham iTBS group at 2 and 4 weeks of follow-up. The secondary outcome showed that the negative symptom score (-3.43 [95% CI, -4.85 to -2.01]; P< .001; ES 0.29) of the active iTBS group was significantly different from that of the sham iTBS group at the 4th week of follow-up. CONCLUSIONS Accelerated iTBS can effectively ameliorate the social cognition and negative symptoms of individuals with schizophrenia. These results suggest that accelerated iTBS may be a safe and effective neuromodulation technique to improve the overall functional recovery of individuals with schizophrenia, and has a good clinical application prospect.
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Affiliation(s)
- Ying Jin
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China.
| | - Jie Tong
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Ying Huang
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Dianhong Shi
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Na Zhu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Minghuan Zhu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Minjia Liu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Haijun Liu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China
| | - Xirong Sun
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China.
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15
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Flanagan RJ, Gee S, Belsey S, Couchman L, Lally J. Therapeutic monitoring of plasma clozapine and N-desmethylclozapine (norclozapine): practical considerations. BJPSYCH ADVANCES 2023. [DOI: 10.1192/bja.2022.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
SUMMARY
Clozapine dose assessment in treatment-refractory schizophrenia is complicated. There is a narrow margin between an effective and a potentially toxic dose and wide inter-individual variation in clozapine metabolic capacity. Moreover, factors such as changes in smoking habit, infection/inflammation, co-prescription of certain drugs, notably fluvoxamine, and age alter the dose requirement within individuals. Therapeutic drug monitoring (TDM) of plasma clozapine and N-desmethylclozapine (norclozapine) can help assess adherence, guide dosage and guard against toxicity. This article gives an overview of clozapine pharmacokinetics and factors affecting clozapine dose requirements. It then outlines the procedures and processes of clozapine TDM, from taking the blood sample for laboratory assay or point-of-contact (finger-prick) testing (POCT) to interpreting and acting on the results.
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16
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Prevalence of clozapine-induced sialorrhea and its effect on quality of life. Psychopharmacology (Berl) 2023; 240:203-211. [PMID: 36538098 DOI: 10.1007/s00213-022-06294-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE Clozapine has proven to be superior to other antipsychotic drugs in the treatment of schizophrenia but is under-prescribed due to its potentially severe side effects. Clozapine-induced sialorrhea (CIS) is a frequent and extremely uncomfortable side effect, which remains understudied. OBJECTIVES To examine the prevalence of diurnal and nocturnal CIS in a sample of patients treated with clozapine, and to evaluate its impact on quality of life. METHODS We conducted a cross-sectional, observational study of 130 patients with schizophrenia spectrum disorders treated with clozapine. The prevalence of CIS was evaluated via specific sialorrhea scales. None of the patients included in the study was receiving a specific treatment for hypersalivation during the study period. Possible associations between sialorrhea and clinical and quality of life variables were analyzed. RESULTS Of 130 subjects, 120 (92.3%) suffered from CIS. Eighty-one (62.31%) suffered from diurnal CIS, 115 (88.56%) from nocturnal CIS, and 85 (65.38%) suffered from both. Significant positive associations between quality of life and diurnal CIS (B = 0.417; p = 2.1e - 6, R2 = 0.156) and nocturnal CIS (B = 0.411; p = 7.7e - 6, R2 = 0.139) were detected. Thirty per cent of the subjects reported a moderate to severe negative impact of sialorrhea on their quality of life. CONCLUSIONS The present study suggests that CIS is highly prevalent in patients with schizophrenia and has an important impact on quality of life in one-third of our sample. Therefore, the inclusion of a systematic evaluation and treatment of CIS in standard clinical practice is highly recommended. TRIAL REGISTRATION Clinical Trials ( https://clinicaltrials.gov ) under reference NCT04197037.
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17
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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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18
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Pennazio F, Brasso C, Villari V, Rocca P. Current Status of Therapeutic Drug Monitoring in Mental Health Treatment: A Review. Pharmaceutics 2022; 14:pharmaceutics14122674. [PMID: 36559168 PMCID: PMC9783500 DOI: 10.3390/pharmaceutics14122674] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/25/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022] Open
Abstract
Therapeutic drug monitoring (TDM) receives growing interest in different psychiatric clinical settings (emergency, inpatient, and outpatient services). Despite its usefulness, TDM remains underemployed in mental health. This is partly due to the need for evidence about the relationship between drug serum concentration and efficacy and tolerability, both in the general population and even more in subpopulations with atypical pharmacokinetics. This work aims at reviewing the scientific literature published after 2017, when the most recent guidelines about the use of TDM in mental health were written. We found 164 pertinent records that we included in the review. Some promising studies highlighted the possibility of correlating early drug serum concentration and clinical efficacy and safety, especially for antipsychotics, potentially enabling clinicians to make decisions on early laboratory findings and not proceeding by trial and error. About populations with pharmacokinetic peculiarities, the latest studies confirmed very common alterations in drug blood levels in pregnant women, generally with a progressive decrease over pregnancy and a very relevant dose-adjusted concentration increase in the elderly. For adolescents also, several drugs result in having different dose-related concentration values compared to adults. These findings stress the recommendation to use TDM in these populations to ensure a safe and effective treatment. Moreover, the integration of TDM with pharmacogenetic analyses may allow clinicians to adopt precise treatments, addressing therapy on an individual pharmacometabolic basis. Mini-invasive TDM procedures that may be easily performed at home or in a point-of-care are very promising and may represent a turning point toward an extensive real-world TDM application. Although the highlighted recent evidence, research efforts have to be carried on: further studies, especially prospective and fixed-dose, are needed to replicate present findings and provide clearer knowledge on relationships between dose, serum concentration, and efficacy/safety.
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Affiliation(s)
- Filippo Pennazio
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
| | - Claudio Brasso
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
- Correspondence:
| | - Vincenzo Villari
- Psychiatric Emergency Service, Department of Neuroscience and Mental Health, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy
| | - Paola Rocca
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
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