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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024; 23:811-831. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [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: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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2
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Alalawi A, Albalawi E, Aljohani A, Almutairi A, Alrehili A, Albalawi A, Aldhafiri A. Decoding Clozapine-Induced Agranulocytosis: Unraveling Interactions and Mitigation Strategies. PHARMACY 2024; 12:92. [PMID: 38921968 PMCID: PMC11207370 DOI: 10.3390/pharmacy12030092] [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: 03/24/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024] Open
Abstract
Agranulocytosis represents a severe complication associated with the administration of clozapine. Clozapine is an antipsychotic medication that has demonstrated substantial efficacy in remediating refractory schizophrenia and various other psychiatric disorders. Nonetheless, it is crucial to monitor patients for neutropenia regularly during clozapine therapy. Therefore, this article aimed to delve into the prevalence of agranulocytosis during clozapine treatment by scrutinizing the extant literature to discern trends and correlations. This review endeavored to explore factors such as drug interactions, dose-related factors, duration of treatment, and genetic predispositions that could potentially influence the likelihood of patients developing agranulocytosis while undergoing clozapine therapy. Moreover, this review enunciates the ramifications of agranulocytosis on both patients and healthcare providers and meticulously evaluates the strategies to mitigate this risk and ensure optimal patient outcomes.
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Affiliation(s)
- Ali Alalawi
- Drug Information Centre, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Enas Albalawi
- Pharmacy Department, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdullah Aljohani
- Medication Safety, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdullah Almutairi
- Inpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Abdulraouf Alrehili
- Outpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Areej Albalawi
- Laboratory Department, Madina Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia;
| | - Ahmed Aldhafiri
- Pharmacology and Toxicology Department, College of Pharmacy, Taibah University, Medina 42353, Saudi Arabia
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3
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Verdoux H, Quiles C, de Leon J. Risks and benefits of clozapine and lithium co-prescribing: A systematic review and expert recommendations. Schizophr Res 2024; 268:233-242. [PMID: 37002013 DOI: 10.1016/j.schres.2023.03.032] [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: 03/01/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES To identify the risks and benefits of clozapine‑lithium co-prescription. METHODS Articles published in English or French were identified with a MEDLINE, Web of Sciences and PsycINFO search, from inception through January 2023, using the term 'clozapine' in combination with 'lithium'. Data were synthesized narratively. RESULTS Of the 67 articles included in the review, more than half (n = 38, 56.7 %) were focused on clozapine-related blood dyscrasia. A body of evidence drawn from case reports and retrospective chart studies highlights the potential benefits of lithium prescription for clozapine-related neutropenia, since this strategy may avoid clozapine discontinuation or allow its rechallenge. The most documented adverse drug reactions (ADRs) associated with clozapine‑lithium co-prescription are neurotoxic events, which may be prevented or detected early by clinical, electroencephalographic and therapeutic drug monitoring. Causality assessment cannot be established for other reported ADRs occurring during clozapine‑lithium co-prescription. The benefits of the combined prescription on psychotic and/or mood symptoms are poorly documented. CONCLUSION The risks and benefits of clozapine‑lithium co-prescription require further exploration as the combination might significantly contribute to reducing underprescription or premature discontinuation of clozapine.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain; Psychiatry and Neurosciences Research Group (CTS-549), USA
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4
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Tan JQE, Dawson JL, Bastiampillai T. Can lithium be used in the setting of clozapine commencement in patients with COVID-19 associated neutropenia: A case report. Clin Case Rep 2024; 12:e8758. [PMID: 38617070 PMCID: PMC11014804 DOI: 10.1002/ccr3.8758] [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: 08/20/2023] [Revised: 03/06/2024] [Accepted: 03/16/2024] [Indexed: 04/16/2024] Open
Abstract
COVID-19 infection may increase the likelihood of neutropenia in patients already on clozapine. In clozapine treated patients experiencing COVID-19 associated neutropenia, adjunct therapy with lithium can be considered.
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Affiliation(s)
- Jin Quan Eugene Tan
- SA Pharmacy, Flinders Medical CentreSouthern Adelaide Local Health NetworkAdelaideSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Jessica L. Dawson
- SA Pharmacy, Flinders Medical CentreSouthern Adelaide Local Health NetworkAdelaideSouth AustraliaAustralia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Tarun Bastiampillai
- Discipline of Psychiatry, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- Department of PsychiatryMonash UniversityClaytonVictoriaAustralia
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5
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Tabrisi R, Harun-Rashid MD, Montero J, Venizelos N, Msghina M. Clozapine but not lithium reverses aberrant tyrosine uptake in patients with bipolar disorder. Psychopharmacology (Berl) 2023; 240:1667-1676. [PMID: 37318540 PMCID: PMC10349740 DOI: 10.1007/s00213-023-06397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
RATIONALE Availability of the dopamine and noradrenaline precursor tyrosine is critical for normal functioning, and deficit in tyrosine transport across cell membrane and the blood-brain barrier has been reported in bipolar disorder and schizophrenia. Clozapine and lithium are two psychoactive agents used to treat psychosis, mood disorders and suicidal behavior, but their mechanism of action remains largely unknown. OBJECTIVE To characterize immediate and delayed differences in tyrosine uptake between healthy controls (HC) and bipolar patients (BP) and see if these differences could be normalized by either clozapine, lithium or both. A second objective was to see if clozapine and lithium have additive, antagonistic or synergistic effects in this. METHOD Fibroblasts from five HC and five BP were incubated for 5 min or 6 h with clozapine, lithium, or combination of both. Radioactive labelled tyrosine was used to quantify tyrosine membrane transport. RESULTS There was significantly reduced tyrosine uptake at baseline in BP compared to HC, a deficit that grew with increasing incubation time. Clozapine selectively increased tyrosine uptake in BP and abolished the deficit seen under baseline conditions, while lithium had no such effect. Combination treatment with clozapine and lithium was less effective than when clozapine was used alone. CONCLUSIONS There was significant deficit in tyrosine transport in BP compared to HC that was reversed by clozapine but not lithium. Clozapine was more effective when used alone than when added together with lithium. Potential clinical implications of this will be discussed.
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Affiliation(s)
- R Tabrisi
- Department of Plastic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M D Harun-Rashid
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Montero
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - N Venizelos
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Msghina
- Department of Psychiatry, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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6
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Corbeil O, Béchard L, Fournier É, Plante M, Thivierge MA, Lafrenière CÉ, Huot-Lavoie M, Brodeur S, Essiambre AM, Roy MA, Demers MF. Clozapine rechallenge or continuation despite neutropenia or agranulocytosis using colony-stimulating factor: A systematic review. J Psychopharmacol 2023; 37:370-377. [PMID: 36794520 PMCID: PMC10363950 DOI: 10.1177/02698811231154111] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Rechallenge/continuation of clozapine in association with colony-stimulating factors (CSFs) following neutropenia/agranulocytosis has been reported, but many questions remain unanswered about efficacy and safety. This systematic review aims to assess the efficacy and safety of rechallenging/continuing clozapine in patients following neutropenia/agranulocytosis using CSFs. METHODS MEDLINE, Embase, PsycInfo, and Web of Science databases were searched from inception date to July 31, 2022. Articles screening and data extraction were realized independently by two reviewers, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 systematic review guidance. Included articles had to report on at least one case where clozapine was rechallenged/continued using CSFs despite previous neutropenia/agranulocytosis. RESULTS Eight hundred forty articles were retrieved; 34 articles met the inclusion criteria, totaling 59 individual cases. Clozapine was successfully rechallenged/continued in 76% of patients for an average follow-up period of 1.9 years. There was a trend toward better efficacy reported in case reports/series, compared with consecutive case series (overall success rates of 84% and 60%, respectively, p-value = 0.065). Two administration strategies were identified, "as-needed" and prophylactic, both yielding similar success rates (81% and 80%, respectively). Only mild and transient adverse events were documented. CONCLUSIONS Although limited by the relatively small number of published cases, factors such as time of onset to first neutropenia and severity of the episode did not seem to impact the outcome of a subsequent clozapine rechallenge using CSFs. While the efficacy of this strategy remains to be further adequately evaluated in more rigorous study designs, its long-term innocuity warrants considering its use more proactively in the management of clozapine hematological adverse events as to maintain this treatment for as many individuals as possible.
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Affiliation(s)
- Olivier Corbeil
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Laurent Béchard
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Émilien Fournier
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
| | - Maude Plante
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada
| | - Marc-André Thivierge
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Maxime Huot-Lavoie
- CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Sébastien Brodeur
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Anne-Marie Essiambre
- CERVO Brain Research Centre, Québec City, QC, Canada.,School of Psychology, Faculty of Social Sciences, Université Laval, Québec City, QC, Canada
| | - Marc-André Roy
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada.,Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Marie-France Demers
- Faculty of Pharmacy, Université Laval, Québec City, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada.,CERVO Brain Research Centre, Québec City, QC, Canada
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7
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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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8
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Shuman M, Moss L, Dilich A. Never Say Never: Successful Clozapine Rechallenge After Multiple Episodes of Neutropenia. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2021; 19:66-70. [PMID: 34483771 DOI: 10.1176/appi.focus.20200029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Clozapine is a second-generation antipsychotic with a superior efficacy for the management of treatment-resistant schizophrenia but underutilized because of potential side effects. A 59-year-old Caucasian male veteran was transferred from the long-term care unit to the acute psychiatry unit because of suicidality. He was noted as having a long-standing history of psychosis with significant referential and paranoid delusions. He had experienced two previous trials of clozapine; although he had significant response in the past, both trials ended in neutropenia and an absolute neutrophil count <500 cells per microliter, despite the second trial also including supplemental "as-needed" doses of pegfilgrastim to manage decline in neutrophil counts. This particular strategy of filgrastim use was determined to be a weakness of the second trial. A PubMed search identified recent literature that discussed preemptive dosing of filgrastim to prevent neutropenia. Thus, a protocol was established to administer 300 μg filgrastim subcutaneously, three times weekly, concurrently with clozapine initiation. This plan was discussed on local and national levels to achieve consensus before its initiation. Using a revised, patient-specific protocol led to successful initiation of clozapine and the ability to maintain the regimen for over 24 months without interruption or any further suicidal ideation.
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Affiliation(s)
- Michael Shuman
- Pharmacy Department, Central State Hospital, Louisville, Kentucky (Shuman); College of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago (Moss); Pharmacy Department, Captain James A. Lovell Federal Health Care Center, North Chicago (Dilich)
| | - Lori Moss
- Pharmacy Department, Central State Hospital, Louisville, Kentucky (Shuman); College of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago (Moss); Pharmacy Department, Captain James A. Lovell Federal Health Care Center, North Chicago (Dilich)
| | - Adam Dilich
- Pharmacy Department, Central State Hospital, Louisville, Kentucky (Shuman); College of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago (Moss); Pharmacy Department, Captain James A. Lovell Federal Health Care Center, North Chicago (Dilich)
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9
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Safety profile of clozapine: Analysis using national registry data in Japan. J Psychiatr Res 2021; 141:116-123. [PMID: 34192602 DOI: 10.1016/j.jpsychires.2021.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
Clozapine is the only effective antipsychotic drug used for the treatment of treatment-resistant schizophrenia. Although it has been shown that the frequency of clozapine use is very low in Japan, our previous study revealed that the number of clozapine prescriptions has been increasing in recent years, and that risk factors leading to discontinuation of clozapine were also identified as age ≥40 years, poor tolerability to olanzapine, previous treatment with clozapine, and white blood cell count <6000/mm3. The main cause for discontinuation of clozapine is the occurrence of a wide range of adverse events, including neutropenia/leukopenia and fatal cardiac disorders. In this study, we analyzed the physical details and backgrounds of patients with adverse events that led to clozapine discontinuation using a national registry database of more than 8000 Japanese patients. The physical adverse events that led to discontinuation of clozapine were neutropenia/leukopenia, glucose intolerance, cardiac disorders, gastrointestinal disorders, neuroleptic malignant syndrome, pleurisy, pulmonary embolism, sedation/somnolence, and seizures. Neutropenia/leukopenia had the highest incidence (5.0%). Neutropenia/leukopenia and cardiac disorders tended to occur early in the treatment period, indicating the need for careful monitoring for these adverse events in the early stages of clozapine treatment. Gastrointestinal disorders occurred over a long period of time, suggesting the need for careful observation during the maintenance period. The data obtained in our study will lead to the optimal and safe use of clozapine treatment.
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Béchard L, Corbeil O, Plante M, Thivierge MA, Lafrenière CÉ, Roy MA, Demers MF. Clozapine rechallenge following neutropenia using granulocyte colony-stimulating factor: A Quebec case series. J Psychopharmacol 2021; 35:1152-1157. [PMID: 34229529 PMCID: PMC8436292 DOI: 10.1177/02698811211029737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine has a unique efficacy profile among individuals suffering from treatment-resistant schizophrenia, but is associated with hematological side effects. The use of granulocyte colony-stimulating factors (G-CSF) to allow clozapine continuation or rechallenge has emerged as a promising option, but evidence is still scarce. AIM To describe the largest case series so far published regarding this practice. METHOD A national clozapine hematological monitoring database was consulted to identify all patients who had had neutrophil count <1.5 × 109/L since 2004 in Quebec and was cross-referenced with hospital pharmacy software to identify patients who had received at least one dose of G-CSF, such as filgrastim, while being exposed to clozapine. All data were collected retrospectively, using patients' medical files, from January to July 2019. RESULTS Using G-CSF, three out of eight patients could maintain clozapine despite neutropenia episodes that otherwise would have required treatment discontinuation. The only side effect reported was mild short-lived back pain, over a mean 3-year follow-up period. In all but one case, filgrastim was used on an "as-needed" basis at doses of 300 mcg administered subcutaneously. CONCLUSION These results suggest that the "as-needed" use of G-CSF is well-tolerated and may allow clozapine rechallenge in some well-selected patients, adding to the paucity of data regarding long-term safety and efficacy of this strategy. More research may help to better define potential candidates and optimal regimen of such practice.
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Affiliation(s)
- Laurent Béchard
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada,Laurent Béchard, Clinique Notre-Dame des Victoires, 2525, chemin de la Canardière, Entrée #A-1-2, Québec (Québec), Canada G1J 2G3.
| | - Olivier Corbeil
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada
| | - Maude Plante
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada
| | - Marc-André Thivierge
- Faculté de pharmacie, Université Laval, Québec, Canada,Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke, Quebec, Canada
| | | | - Marc-André Roy
- Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Département de psychiatrie et neurosciences, Faculté de médecine, Université Laval, Canada,Centre de recherche CERVO, Québec, Canada
| | - Marie-France Demers
- Faculté de pharmacie, Université Laval, Québec, Canada,Institut universitaire en santé mentale de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec, Canada,Centre de recherche CERVO, Québec, Canada
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11
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Silva E, Higgins M, Hammer B, Stephenson P. Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital. Ther Adv Psychopharmacol 2021; 11:20451253211015070. [PMID: 34221348 PMCID: PMC8221694 DOI: 10.1177/20451253211015070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer. METHODS A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes. RESULTS Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient's had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion. CONCLUSION Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.
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Affiliation(s)
- Edward Silva
- Rathbone Low Secure Unit, Mersey Care NHS Foundation Trust, Rathbone Hospital, Mill Lane, Liverpool, L13 4AW, UK
| | - Melanie Higgins
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Liverpool, UK
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12
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Flanagan RJ, Lally J, Gee S, Lyon R, Every-Palmer S. Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals. Br Med Bull 2020; 135:73-89. [PMID: 32885238 PMCID: PMC7585831 DOI: 10.1093/bmb/ldaa024] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clozapine remains the only medication licensed for treating refractory schizophrenia. However, it remains underutilized in part due to concerns regarding adverse events. SOURCES OF DATA Published literature. AREAS OF AGREEMENT Common adverse events during clozapine treatment include sedation, hypersalivation, postural hypotension, dysphagia, gastrointestinal hypomotility, weight gain, diabetes mellitus and dyslipidaemia. Rare but serious events include agranulocytosis, cardiomyopathy, myocarditis, pneumonia, paralytic ileus and seizure. AREAS OF CONTROVERSY It remains unclear how best to minimize clozapine-induced morbidity/mortality (i) during dose titration, (ii) from hypersalivation and (iii) from gastrointestinal hypomotility. It is also unclear how clozapine pharmacokinetics are affected by (i) gastrointestinal hypomotility, (ii) systemic infection and (iii) passive exposure to cigarette smoke. Whether monthly haematological monitoring needs to continue after 12 months of uninterrupted therapy is also a subject of debate. GROWING POINTS There is a need for better management of serious clozapine-related adverse events in addition to agranulocytosis. There is also a need for better education of patients and carers, general practitioners, A&E and ITU staff and others of the problems posed in using clozapine safely. AREAS TIMELY FOR DEVELOPING RESEARCH There is a need for more research on assessing clozapine dosage (i) as patients get older, (ii) with respect to exposure to cigarette smoke and (iii) optimizing response if adverse events or other factors limit dosage.
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Affiliation(s)
- R J Flanagan
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
| | - J Lally
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.,Department of Psychiatry, Mater Misericordiae University Hospital, 63 Eccles Street, Dublin 7, Ireland.,Department of Psychiatry, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - S Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, UK
| | - R Lyon
- Department of Pharmacy, Sussex Partnership NHS Foundation Trust, Chichester Centre, Graylingwell Drive, Chichester, West Sussex PO19 6GS UK
| | - S Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, PO Box 7343, Newtown, Wellington 6242, NZ
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Luykx JJ, Stam N, Tanskanen A, Tiihonen J, Taipale H. In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine. Br J Psychiatry 2020; 217:498-505. [PMID: 31910911 PMCID: PMC7511905 DOI: 10.1192/bjp.2019.267] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided. AIMS To compare the real-world effectiveness of antipsychotics after clozapine cessation. METHOD From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences. RESULTS Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001). CONCLUSIONS Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.
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Affiliation(s)
- Jurjen J. Luykx
- Assistant Professor, Departmentsof Psychiatry and Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University; and Department of Outpatient Psychiatry, GGNet Mental Health, The Netherlands,Correspondence: Jurjen J. Luykx.
| | - Noraly Stam
- Researcher, Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Antti Tanskanen
- Researcher, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Public Health Solutions, National Institute for Health and Welfare, Finland
| | - Jari Tiihonen
- Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Finland; and Center for Psychiatric Research, Stockholm City Council, Sweden
| | - Heidi Taipale
- Assistant Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Academy Research Fellow, Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Associate Professor, School of Pharmacy, University of Eastern Finland, Finland
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Silva E, Higgins M, Hammer B, Stephenson P. Clozapine rechallenge and initiation despite neutropenia- a practical, step-by-step guide. BMC Psychiatry 2020; 20:279. [PMID: 32503471 PMCID: PMC7275543 DOI: 10.1186/s12888-020-02592-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 04/07/2020] [Indexed: 12/16/2022] Open
Abstract
Clozapine remains the only drug treatment likely to benefit patients with treatment resistant schizophrenia. Its use is complicated by an increased risk of neutropenia and so there are stringent monitoring requirements and restrictions in those with previous neutropenia from any cause or from clozapine in particular. Despite these difficulties clozapine may yet be used following neutropenia, albeit with caution. Having had involvement with 14 cases of clozapine use in these circumstances we set out our approach to the assessment of risks and benefits, risk mitigation and monitoring with a practical guide.
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Affiliation(s)
- Edward Silva
- Consultant Forensic Psychiatrist, Ashworth Hospital, Mersey Care NHS Foundation Trust, Parkbourn, Maghull, Merseyside, L31 1HW, UK.
| | - Melanie Higgins
- Consultant Forensic Psychiatrist, Ashworth Hospital, Mersey Care NHS Foundation Trust, Parkbourn, Maghull, Merseyside, L31 1HW, UK
| | - Barbara Hammer
- Consultant Haematologist, Arrowe Park Hospital, Arrowe Park Road, Upton, Merseyside, Wirral, CH49 5PE, UK
| | - Paul Stephenson
- Consultant Forensic Psychiatrist, Ashworth Hospital, Mersey Care NHS Foundation Trust, Parkbourn, Maghull, Merseyside, L31 1HW, UK
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