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Leung JG, Zhang L, Markota M, Ellingrod VL, Gerberi DJ, Bishop JR. A systematic review of clozapine-associated inflammation and related monitoring. Pharmacotherapy 2023; 43:1364-1396. [PMID: 37842767 DOI: 10.1002/phar.2887] [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: 07/13/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/17/2023]
Abstract
Clozapine is an effective antipsychotic medication used for treatment-resistant schizophrenia. However, it is underutilized due to rigorous hematologic monitoring requirements and many adverse drug reactions. Publications have highlighted the occurrence of inflammatory reactions, some life-threatening, particularly during the early stages of clozapine treatment. Although guidelines have suggested monitoring for inflammatory processes during clozapine initiation, screening in clinical practice is not universal. This systematic review aimed to investigate the relationship between clozapine and inflammation and assess the importance of monitoring for inflammatory reactions. A comprehensive literature search yielded 6915 unique publication records after removal of duplicates. After a rigorous screening process, 75 publications were included in the review, which focused on three main aspects: (i) the impact of clozapine on inflammatory markers, (ii) monitoring cardiac and other organ function during clozapine-associated inflammatory processes, and (iii) monitoring non-specific signs and symptoms of inflammation. Elevated levels of C-reactive protein (CRP) and several proinflammatory cytokines have been observed in association with clozapine treatment. However, the practicality of measuring specific markers in clinical practice remains uncertain. Current evidence supports monitoring CRP levels during the first 4-8 weeks of treatment, especially to facilitate myocarditis screening. Further research is needed to establish clinically relevant CRP thresholds for intervention. The implementation of monitoring protocols during the early phase of clozapine treatment may mitigate adverse reactions and allow for continued use of clozapine. Future studies should also explore the association between clozapine-associated inflammation and pneumonia, as well as investigate the impact of inflammation on clozapine metabolism to predict the need for dose adjustment. These endeavors may facilitate the development and implementation of evidence-based guidelines for the monitoring of clozapine-associated inflammation.
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Affiliation(s)
| | - Lusi Zhang
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Matej Markota
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vicki L Ellingrod
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Das S, Itrat A, Hernandez MET, Subedi R, Jogarajah T, Vashist S, Daggala N. Clozapine-induced eosinophilia: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231195961. [PMID: 37667744 PMCID: PMC10475262 DOI: 10.1177/2050313x231195961] [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: 06/02/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
Schizophrenia is a chronic neuropsychiatric illness defined by the appearance of positive, and negative symptoms and/or cognitive impairment. Antipsychotic drugs are predominantly used in the treatment of psychotic disorders, but not all patients with schizophrenia respond to every antipsychotic medication. Clozapine is one of the best atypical antipsychotics and is highly effective in treating treatment-resistant schizophrenia. Evidence suggests that clozapine appears to be effective in lowering the risk of suicide, extrapyramidal side effects, and relapse in patients with schizophrenia. Per contra, clozapine is not the first-line treatment due to its unalterable aftereffects such as agranulocytosis, metabolic syndrome, seizures, and rarely, eosinophilia. Eosinophilia can be life-threatening. Eosinophils infiltrate different tissues and cause inflammation in multiple organs causing end-organ damage. The current study aimed to report the incidence of eosinophilia associated with clozapine use in patients with schizophrenia. Literature on clozapine-induced eosinophilia is relatively scarce. Understanding the progression and management of clozapine-induced eosinophilia and its end-organ effects is imperative. While there is insufficient data about the guidelines in the management of clozapine-induced eosinophilia, this study contributes to understanding the patterns of the disease progression with clozapine dosage. A case study was done on a patient with schizophrenia and autistic spectrum disorder who was on clozapine. Data on how eosinophil levels varied with clozapine dosing was analyzed and documented. The evidence of clozapine dosage affecting eosinophil and C-reactive protein levels in this patient was summarized in a table and a narrative review.
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Affiliation(s)
- Soumitra Das
- Emergency Mental Health, Sunshine Hospital, Melbourne, VIC, Australia
| | - Annie Itrat
- Broadmeadows Inpatient Unit, Northern Health, Broadmeadows, VIC, Australia
| | | | - Rasish Subedi
- Universal College of Medical Sciences, Bhairahawa, Nepal
| | - Thusanth Jogarajah
- Faculty of Medicine, Richmond Gabriel University, Belair, Saint Vincent and the Grenadines
| | | | - Nikitha Daggala
- Windsor University School of Medicine, Cayon, Saint Kitts and Nevis
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Grover S, Kathiravan S. Clozapine research from India: A systematic review. Asian J Psychiatr 2023; 79:103353. [PMID: 36493690 DOI: 10.1016/j.ajp.2022.103353] [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: 10/02/2022] [Revised: 11/09/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area. AIM We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010. METHODOLOGY A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included. RESULTS Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine. CONCLUSION Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Allergic to Clozapine: A Case of Clozapine-Associated Eosinophilia With Pleural Effusions Followed by Pancreatitis on Clozapine Rechallenge. J Clin Psychopharmacol 2020; 40:199-200. [PMID: 32134858 DOI: 10.1097/jcp.0000000000001187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Filippis R, Soldevila-Matías P, De Fazio P, Guinart D, Fuentes-Durá I, Rubio JM, Kane JM, Schoretsanitis G. Clozapine-related drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a systematic review. Expert Rev Clin Pharmacol 2020; 13:875-883. [PMID: 32576056 DOI: 10.1080/17512433.2020.1787831] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe, multiorganic, and potentially life-threatening drug-induced hypersensitivity reaction, linked to several common drugs, including antiepileptics, antibiotics, and several psychotropic drugs, including clozapine. Due to the importance of clozapine in the management of treatment-resistant schizophrenia, a systematic review and characterization of clozapine-related DRESS syndrome is long overdue. AREAS COVERED This systematic review was conducted following PRISMA guidelines. PubMed, Embase, PsychINFO, and the Cochrane Library databases were independently reviewed up to 1 November 2019 for articles reporting clozapine-related DRESS syndrome cases. The RegiSCAR score system was applied to systematically characterize the clinical presentations of selected studies. EXPERT OPINION Clozapine-related DRESS syndrome was reported in six patients from four articles. Five patients received polypharmacy. Skin rash and liver involvement with elevated liver enzymes were very common. No fatal cases were found. Treatment mainly included clozapine discontinuation and immunosuppression. The mismatch between incidences of DRESS with other responsible drugs, the common misdiagnosis of this syndrome, and the fact that an extensive literature search only identified six cases suggests that clozapine-related DRESS may be overlooked. It is, therefore, necessary to optimize diagnostic strategies to identify immune-related side effects of clozapine.
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Affiliation(s)
- Renato de Filippis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro , Catanzaro, Italy
| | - Pau Soldevila-Matías
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Research Institute of Clinic University Hospital of Valencia (INCLIVA) , Valencia, Spain
| | - Pasquale De Fazio
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro , Catanzaro, Italy
| | - Daniel Guinart
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA
| | - Inmaculada Fuentes-Durá
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Valencia , Valencia, Spain
| | - Jose M Rubio
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research , Manhasset, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health , Glen Oaks, NY, USA.,Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra , Hempstead, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research , Manhasset, NY, USA
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Rechallenge Following Clozapine-Associated Eosinophilia: A Case Report and Literature Review. J Clin Psychopharmacol 2020; 39:504-506. [PMID: 31335444 DOI: 10.1097/jcp.0000000000001079] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Marchel D, Hart AL, Keefer P, Vredeveld J. Multiorgan eosinophilic infiltration after initiation of clozapine therapy: a case report. BMC Res Notes 2017; 10:316. [PMID: 28743303 PMCID: PMC5526284 DOI: 10.1186/s13104-017-2662-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The eosinophilic response to clozapine is well described in the literature, causing a variety of responses, from serositis to colitis. However, there are not case reports describing a clozapine-induced marked eosinophilia resulting in multiorgan dysfunction. CASE PRESENTATION In this case report, we describe a 24 year old Caucasian male who presented with severe systemic eosinophilia resulting in eosinophilic GI tract infiltration, myocarditis, pericardial and pleural effusions with dramatic improvement following drug withdrawal. CONCLUSIONS Clozapine associated eosinophilia should be suspected in the setting of eosinophilic infiltration of multiple organs.
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Affiliation(s)
- Dorota Marchel
- Pediatric Primary Care Clinic, Rutledge Tower, 3rd Floor, 135 Rutledge Avenue, MSC 560, Charleston, SC 29425 USA
| | - Anita L. Hart
- University of Michigan Health System, 1500 East Medical Center Drive, Room 3119 TC, Ann Arbor, MI 48109-5376 USA
| | - Patricia Keefer
- University of Michigan Health System, 1540 East Medical Center Drive, SPC 4280, Mott 12-525, Ann Arbor, MI 48109-4280 USA
| | - Jennifer Vredeveld
- University of Michigan Health System, 1540 East Medical Center Drive, SPC 4280, Mott 12-525, Ann Arbor, MI 48109-4280 USA
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Kadiyala PK, Ahmed MA, Pinto DA, Mathai JP. Clozapine induced eosinophilia: An often neglected important adverse effect. Indian J Psychiatry 2015; 57:429-30. [PMID: 26816437 PMCID: PMC4711251 DOI: 10.4103/0019-5545.171849] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Pavan Kumar Kadiyala
- Department of Psychiatry, Fr. Muller Medical College, Mangalore, Karnataka, India. E-mail:
| | - Maldar A Ahmed
- Department of Psychiatry, Fr. Muller Medical College, Mangalore, Karnataka, India. E-mail:
| | - Denzil A Pinto
- Department of Psychiatry, Fr. Muller Medical College, Mangalore, Karnataka, India. E-mail:
| | - John P Mathai
- Department of Psychiatry, Fr. Muller Medical College, Mangalore, Karnataka, India. E-mail:
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