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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 PMCID: PMC11316720 DOI: 10.1007/s40263-024-01100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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2
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Stahl SM, Djokic G. Comparing the pharmacology and pharmacokinetics of antipsychotics: Choosing an antipsychotic and dosing a long-acting injectable. Eur Neuropsychopharmacol 2023; 73:108-118. [PMID: 37182458 DOI: 10.1016/j.euroneuro.2023.04.015] [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: 03/05/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/16/2023]
Abstract
In this paper, we will discuss the pharmacologic properties of antipsychotics, including those that are the same in structure and those that differentiate one from another. We will bring to you how differential pharmacologic properties can explain differential efficacy and differential tolerability. We will review how to use plasma drug levels and long-acting injectables to enhance compliance early in the illness, and to manage both forms of treatment resistance (pharmacokinetic and pharmacodynamic failures). Through inadequate pharmacokinetic processes (poor absorption, rapid metabolism, enzymatic polymorphisms, etc.), antipsychotic plasma levels do not reach sufficient concentration. Pharmacodynamic treatment failure (receptor binding and sensitivity, post-receptor effects, etc.) is the inability to provide a significant effect on psychotic symptoms despite therapeutic plasma levels. Long-Acting Injectable (LAI) antipsychotics employ technology that can provide a useful treatment tool in the armamentarium of a modern psychopharmacologist. The pharmacologic properties of antipsychotics differentiate one from another and can help explain differences in efficacy and tolerability. Utilizing plasma drug levels can enhance understanding of treatment failures and lead to specific patient management strategies for best outcomes. This kind of personalized approach to antipsychotic dosage would mean a big shift in the treatment of psychiatric patients.
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Affiliation(s)
- Stephen M Stahl
- Neuroscience Education Institute, Carlsbad, USA; Department of Psychiatry, University of California, San Diego School of Medicine, USA; Psychopharmacology California Department of State Hospitals, USA; University of Cambridge, Cambridge, UK
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3
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Daniel P, Rajaree KM, Rudy L, Jafor S, Prasad S, Avanthika C, Jhaveri S. Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates. Heliyon 2023; 9:e13930. [PMID: 36923851 PMCID: PMC10008991 DOI: 10.1016/j.heliyon.2023.e13930] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/17/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed. Methodology An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management. Results The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects. Conclusion Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.
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Affiliation(s)
| | | | - Luna Rudy
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sadeque Jafor
- Al Mostaqbal Hospital, Jeddah, Kingdom of Saudi Arabia
| | - Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, 21018, Vinnytsya, Ukraine
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4
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Ansari S, Kelbrick M, Paduret G, Diaz N, Menzel R, Rogers R, Wareham C, Griffiths C, Jugon S, Tidy K, Johnson S, Mann N, Tanner J, Millward T, Latif S. Clinical practice guideline for clozapine use in patients with
COVID
‐19. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2023. [DOI: 10.1002/pnp.779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Saba Ansari
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Marlene Kelbrick
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Gabriela Paduret
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Natasha Diaz
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Rose Menzel
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Rowena Rogers
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Claire Wareham
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Chris Griffiths
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Sue Jugon
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Katy Tidy
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Sara Johnson
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Nick Mann
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - James Tanner
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Tim Millward
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
| | - Shahid Latif
- Dr Ansari is a Specialty Registrar (ST5); Dr Kelbrick is a Consultant Psychiatrist; Dr Paduret is a Core Trainee Year 2; Ms Diaz is a Physical Health Advanced Nurse Practitioner; Ms Menzel is a Pharmacist; Ms Rowena Rogers is a Community Mental Health Nurse; Ms Wareham is a Community Mental Health Nurse; Dr Griffiths is a Senior Research and Evaluation Fellow; Ms Jugon is a EIP operations Manager; Ms Tidy is a CMHT Operations Manager; Ms Johnson is a Ward Matron; Dr Mann, Dr Tanner, Dr Millward, Dr
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5
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Brazile T, Barakat AF, Bukhari S, Schelbert EB, Soman P. A 25-Year-Old Man with Refractory Schizophrenia and Clozapine-Induced Myocarditis Diagnosed by Non-Invasive Cardiovascular Magnetic Resonance. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930103. [PMID: 33990535 PMCID: PMC8130977 DOI: 10.12659/ajcr.930103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient: Male, 25-year-old Final Diagnosis: Clozapine-induced myocarditis Symptoms: Elevated troponin • fever • leukocytosis • somnolence • tachycardia Medication: — Clinical Procedure: Cardiovascular magnetic resonance • electrocardiogram • transthoracic echocardiogram Specialty: Cardiology • General and Internal Medicine
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Affiliation(s)
- Tiffany Brazile
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amr F Barakat
- Department of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Syed Bukhari
- Department of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Erik B Schelbert
- Department of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Prem Soman
- Department of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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6
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Chrétien B, Fedrizzi S, Lelong-Boulouard V, Sassier M, Alexandre J, Dolladille C. Could N-acetylcysteine improve the safety of clozapine? Hum Psychopharmacol 2021; 36:e2769. [PMID: 33206415 DOI: 10.1002/hup.2769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 01/20/2023]
Abstract
Clozapine is an atypical antipsychotic indicated in patients with treatment-resistant schizophrenia which remains underused due to safety issues. Mechanisms behind these adverse effects are complex and not fully understood. They may involve immune-related mechanisms, direct toxic effects and oxidative stress. Clozapine-induced oxidative stress might indeed notably be involved in the onset of neutropenia, agranulocytosis, myocarditis, sialorrhea, and metabolic alterations. Therefore, the association of N-acetylcysteine (NAC), an easily accessible, low-cost and well tolerated antioxidant drug could be of interest in clozapine-treated patients to improve clozapine safety. Furthermore, according to recent studies NAC could help to improve schizophrenia symptoms. We believe that the use of NAC in the context of clozapine prescribing merits further study, as it could improve clozapine safety which may lead to a wider use and ultimately improve the healthcare of thousands of patients. NAC could also secondarily show positive knock-on effects for the patients by improving clinical symptoms of schizophrenia in synergy with clozapine, and by reducing substance abuse and thus by improving the patient's overall condition. However, given the rarity of clozapine-induced severe adverse effects, only a large volume of data (e.g., National adverse events monitoring) could assess the benefits of NAC on clozapine safety.
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Affiliation(s)
- Basile Chrétien
- Department of Pharmacology, Caen University Hospital, Caen, France.,Pharmacovigilance Regional Center, Caen University Hospital, Caen, France
| | - Sophie Fedrizzi
- Department of Pharmacology, Caen University Hospital, Caen, France.,Pharmacovigilance Regional Center, Caen University Hospital, Caen, France
| | | | - Marion Sassier
- Department of Pharmacology, Caen University Hospital, Caen, France.,Pharmacovigilance Regional Center, Caen University Hospital, Caen, France
| | - Joachim Alexandre
- Department of Pharmacology, Caen University Hospital, Caen, France.,Pharmacovigilance Regional Center, Caen University Hospital, Caen, France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Normandie Univ, UNICAEN, Caen University Hospital, Caen, France
| | - Charles Dolladille
- Department of Pharmacology, Caen University Hospital, Caen, France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Normandie Univ, UNICAEN, Caen University Hospital, Caen, France
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7
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Cundari G, Galea N, De Rubeis G, Frustaci A, Cilia F, Mancuso G, Marchitelli L, Catapano F, Carbone I, Catalano C, Francone M. Use of the new Lake Louise Criteria improves CMR detection of atypical forms of acute myocarditis. Int J Cardiovasc Imaging 2020; 37:1395-1404. [PMID: 33190198 PMCID: PMC8026431 DOI: 10.1007/s10554-020-02097-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
The purpose of our study was to compare diagnostic performance of old and new Lake Louise Criteria (oLLC and nLLC) among different clinical presentations: infarct-like (IL), cardiomyopathic (CM) and arrhythmic (AR). 102 patients with clinical suspicion of acute myocarditis underwent cardiac magnetic resonance (CMR) on a 1.5 T scanner. Protocol included cine-SSFP, T2-weighted STIR, T2 mapping, early and late gadolinium enhancement and T1 mapping acquired before and after gadolinium administration. The degree of agreement has been calculated with Cohen's K test. 42 patients also underwent endomyocardial biopsy (EMB). IL onset was present in 54/102 patients, CM in 28/102 and AR in 20/102. nLLC were positive in 58.3% of the patients, while oLLC in 37.9%, k = 0.57 (IC: 0.428-0.713). The degree of agreement between nLLC and oLLC was 0.49 (IC: 0.111-0.876) for AR onset (nLLC positive in 35% vs oLLC in 15%), 0.25 (IC: 0.035-0.459) for CM pattern (nLLC positive in 60.7% vs oLLC 17.9%) and 0.73 (IC: 0.543-0.912) for IL presentation (nLLC positive in 66.7% vs oLLC in 57.4%). Diagnostic accuracy was 75% for both nLLC and oLLC among IL onset, and 41.6% for oLLC vs 66.7% for nLLC, as regards CM clinical presentation. nLLC have improved diagnostic performance of CMR for the diagnosis of acute myocarditis, in particular for atypical clinical presentation.
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Affiliation(s)
- Giulia Cundari
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - Nicola Galea
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Gianluca De Rubeis
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Frustaci
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Cilia
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Mancuso
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Federica Catapano
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Iacopo Carbone
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Francone
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
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8
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Shivakumar G, Thomas N, Sollychin M, Takács A, Kolamunna S, Melgar P, Connally F, Neil C, Bousman C, Jayaram M, Pantelis C. Protocol for Clozapine Rechallenge in a Case of Clozapine-Induced Myocarditis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:448-453. [PMID: 31818135 PMCID: PMC7298578 DOI: 10.1177/0706743719892709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Protocol for clozapine rechallenge in patients with a history of clozapine-induced myocarditis. METHOD Clozapine-related cardiovascular adverse effects including myocarditis and cardiomyopathy have limited its widespread use in treatment-resistant schizophrenia. Here, we present a case of clozapine-induced myocarditis and successful cautious rechallenge. Ms. AA, a young female patient with severe psychosis developed myocarditis during her initial clozapine titration phase, which was thus discontinued. Subsequent response to other medications was poor, and she remained significantly disabled. We reviewed blood-based biomarkers identified during the emergence of her index episode of myocarditis and developed a successful clozapine rechallenge protocol, based on careful monitoring of changes in these indices and a very slow clozapine re-titration. RESULTS AND CONCLUSIONS This protocol may have utility in the management of patients with a history of clozapine-induced myocarditis.
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Affiliation(s)
- G Shivakumar
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - N Thomas
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health, Research & Education, St Albans, Victoria, Australia
| | - M Sollychin
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - A Takács
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - S Kolamunna
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - P Melgar
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - F Connally
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - C Neil
- Western Health, Department of Cardiology, University of Melbourne, Victoria, Australia
| | - C Bousman
- Department of Medical Genetics, University of Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Alberta, Canada.,Department of Physiology and Pharmacology, University of Calgary, Alberta, Canada
| | - M Jayaram
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health, Research & Education, St Albans, Victoria, Australia
| | - C Pantelis
- Adult Mental Health Rehabilitation Unit, North Western Mental Health, Melbourne Health, Western Health, Sunshine Hospital, St Albans, Victoria, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Western Centre for Health, Research & Education, St Albans, Victoria, Australia
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9
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Abstract
Clozapine is a dibenzodiazepine antipsychotic used for treatment-resistant schizophrenia. Its association with several side effects such as agranulocytosis, seizure, and insulin resistance is well known. Cardiac side effects such as myocarditis and cardiomyopathy are less common and have been seldom reported. Here we report an unusual case of clozapine-induced nonischemic dilated cardiomyopathy. A 50-year-old female with treatment-resistant schizophrenia on clozapine presented with gradually worsening shortness of breath, productive cough, and pleuritic chest pain. She was found to have non-ischemic dilated cardiomyopathy due to clozapine use as no other causative factor was found. Clozapine was gradually tapered and then discontinued. Repeat echocardiogram in three months revealed improvement in ejection fraction. This case is unique as it outlines clozapine as a rare cause of nonischemic cardiomyopathy, as discontinuation of the drug showed improvement in symptoms and heart function.
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Affiliation(s)
- Abhinav Garg
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
| | - Anandbir S Bath
- Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, USA
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