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Shier V, Bae-Shaaw YH, Sood N, Lekovitch C, Chew F, Leland NE. The Impact of State Dementia Training Requirements for Nursing Homes on Antipsychotic Medication Use. J Am Med Dir Assoc 2024; 25:209-214.e1. [PMID: 38008125 DOI: 10.1016/j.jamda.2023.10.017] [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: 07/20/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVES Nursing home (NH) staff often report not having adequate dementia-specific knowledge to effectively care for these residents. Between 2011 and 2019, 9 states in the United States implemented dementia training requirements for NH staff. This study evaluated whether the state-mandated dementia training for NH staff was associated with improving resident outcomes. DESIGN Compared trends in antipsychotic medication before and after implementation of state training requirements to trends in states without requirements. SETTING AND PARTICIPANTS NHs. METHODS Data from Care Compare for NHs and LTCFocus were linked to state policy data. We excluded 14 states that had implemented training requirements before the start of the study period in 2011. We estimated difference-in-differences models that compared trends in antipsychotic medication use before and after implementation of training requirements in states that have newly implemented requirements to trends in states without requirements. We also investigated whether the impact of training was larger in states with more stringent training requirements (eg, specifying a minimum number of training hours) and in NHs with a special care unit for dementia and examined similar analyses for restraint use and falls. RESULTS We found that training requirements were associated with a 0.59-percentage point reduction (95% CI -0.91 to -0.27) in antipsychotics use. Effects were larger in NHs with a special care unit for dementia and in states that had stricter training requirements. We also found that training requirements were associated with a 0.17-percentage point reduction (95% CI -0.26 to -0.07) in restraint use measure and had no impact on falls. CONCLUSIONS AND IMPLICATIONS State requirements for NH staff dementia training were associated with a small, but significant, reduction in the use of antipsychotic medication and physical restraints.
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Affiliation(s)
- Victoria Shier
- Schaeffer Center for Health Policy & Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA.
| | - Yuna H Bae-Shaaw
- Titus Family Department of Clinical Pharmacy, USC Mann School of Pharmacy and Pharmaceutical Sciences, University of California, Los Angeles, CA, USA
| | - Neeraj Sood
- Schaeffer Center for Health Policy & Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Cara Lekovitch
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Felicia Chew
- Department of Occupational Therapy, Thomas Jefferson University, Pittsburgh, PA, USA
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
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Fukuyama K, Motomura E, Okada M. A Novel Gliotransmitter, L-β-Aminoisobutyric Acid, Contributes to Pathophysiology of Clinical Efficacies and Adverse Reactions of Clozapine. Biomolecules 2023; 13:1288. [PMID: 37759688 PMCID: PMC10526296 DOI: 10.3390/biom13091288] [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: 07/28/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Clozapine is listed as one of the most effective antipsychotics and has been approved for treating treatment-resistant schizophrenia (TRS); however, several type A and B adverse reactions, including weight gain, metabolic complications, cardiotoxicity, convulsions, and discontinuation syndromes, exist. The critical mechanisms of clinical efficacy for schizophrenia, TRS, and adverse reactions of clozapine have not been elucidated. Recently, the GABA isomer L-β-aminoisobutyric acid (L-BAIBA), a protective myokine in the peripheral organs, was identified as a candidate novel transmission modulator in the central nervous system (CNS). L-BAIBA activates adenosine monophosphate-activated protein kinase (AMPK) signalling in both the peripheral organs and CNS. Activated AMPK signalling in peripheral organs is an established major target for treating insulin-resistant diabetes, whereas activated AMPK signalling in the hypothalamus contributes to the pathophysiology of weight gain and metabolic disturbances. Clozapine increases L-BAIBA synthesis in the hypothalamus. In addition, the various functions of L-BAIBA in the CNS have recently been elucidated, including as an activator of GABA-B and group-III metabotropic glutamate (III-mGlu) receptors. Considering the expressions of GABA-B and III-mGlu receptors (localised in the presynaptic regions), the activation of GABA-B and III-mGlu receptors can explain the distinct therapeutic advantages of clozapine in schizophrenia or TRS associated with N-methyl-D-aspartate (NMDA) receptor disturbance compared with other atypical antipsychotics via the inhibition of the persistent tonic hyperactivation of thalamocortical glutamatergic transmission in the prefrontal cortex. L-BAIBA has also been identified as a gliotransmitter, and a detailed exploration of the function of L-BAIBA in tripartite synaptic transmission can further elucidate the pathophysiology of effectiveness for treating TRS and/or specific adverse reactions of clozapine.
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Affiliation(s)
| | | | - Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (E.M.)
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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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Jamilian H, Ghaderi A. The Effects of Probiotic and Selenium Co-supplementation on Clinical and Metabolic Scales in Chronic Schizophrenia: a Randomized, Double-blind, Placebo-Controlled Trial. Biol Trace Elem Res 2021; 199:4430-4438. [PMID: 33409919 DOI: 10.1007/s12011-020-02572-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/28/2020] [Indexed: 12/20/2022]
Abstract
This study evaluated the effects of probiotic and selenium co-supplementation on clinical and metabolic symptoms in patients with chronic schizophrenia. A randomized, double-blind, placebo-controlled trial was conducted among 60 people with chronic schizophrenia to receive either 8 × 109 CFU/day probiotic plus 200 μg/day selenium (n = 30) or placebo (n = 30) for 12 weeks. Probiotic and selenium co-supplementation resulted in a significant improvement in the general Positive and Negative Syndrome Scale (PANSS) score (β - 1.29; 95% CI, - 2.48, - 0.10; P = 0.03) compared with the placebo. Compared with the placebo, probiotic and selenium co-supplementation resulted in a significant elevation in total antioxidant capacity (β 91.09 mmol/L; 95% CI, 35.89, 146.30; P = 0.002) and total glutathione (β 96.50 μmol/L; 95% CI, 26.13, 166.87; P = 0.008) and a significant reduction in high-sensitivity C-reactive protein levels (β - 1.44 mg/L; 95% CI, - 2.22, - 0.66; P = 0.001). Additionally, co-supplementation significantly decreased fasting glucose (β - 7.40 mg/dL; 95% CI, - 10.15, - 4.64; P < 0.001), insulin levels (β - 1.46 μIU/mL; 95% CI, - 2.35, - 0.57; P = 0.002), and homeostasis model of assessment-insulin resistance (β - 0.51; 95% CI, - 0.72, - 0.29; P < 0.001) and a significant increase in quantitative insulin sensitivity check index (β 0.01; 95% CI, 0.006, 0.01; P < 0.001) compared with the placebo. Probiotic and selenium co-supplementation for 12 weeks to patients with chronic schizophrenia had beneficial effects on the general PANSS score and some metabolic profiles. http://www.irct.ir , identifier IRCT20170513033941N41.
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Affiliation(s)
- Hamidreza Jamilian
- Department of Psychiatry, Arak University of Medical Sciences, Arak, Iran
| | - Amir Ghaderi
- Clinical Research Development Unit-Matini/Kargarnejad Hospital, Kashan University of Medical Sciences, Kashan, IR, Iran.
- Department of Addiction studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran.
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Addressing physical health in mental illness: the urgent need to translate evidence-based interventions into routine clinical practice. Ir J Psychol Med 2021; 38:1-5. [PMID: 33715645 DOI: 10.1017/ipm.2021.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
People affected by severe mental health disorders have a greatly reduced life expectancy compared to their non-affected peers. Cardiovascular disease is the main contributor to this early mortality, caused by higher rates of smoking, physical inactivity, unhealthy diet, sleep disturbance, excessive alcohol use or substance abuse and medication side effects. Therefore, we need to take a preventative approach and translate effective interventions for physical health into routine clinical practice. These interventions should be delivered across all stages of mental health disorders and could also have the added benefit of leading to improvements in mental health. Furthermore, we need to advocate to ensure that people affected by severe mental health disorders receive the appropriate medical assessments and treatments when indicated. This themed issue highlights that physical health is now an urgent priority for funding and development in mental health services. The widespread implementation of evidence-based interventions into routine clinical practice is an essential need for consideration by clinicians and policymakers.
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Chang GR, Liu HY, Yang WC, Wang CM, Wu CF, Lin JW, Lin WL, Wang YC, Lin TC, Liao HJ, Hou PH, Chan CH, Lin CF. Clozapine Worsens Glucose Intolerance, Nonalcoholic Fatty Liver Disease, Kidney Damage, and Retinal Injury and Increases Renal Reactive Oxygen Species Production and Chromium Loss in Obese Mice. Int J Mol Sci 2021; 22:ijms22136680. [PMID: 34206460 PMCID: PMC8268139 DOI: 10.3390/ijms22136680] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/09/2021] [Accepted: 06/18/2021] [Indexed: 12/18/2022] Open
Abstract
Clozapine is widely employed in the treatment of schizophrenia. Compared with that of atypical first-generation antipsychotics, atypical second-generation antipsychotics such as clozapine have less severe side effects and may positively affect obesity and blood glucose level. However, no systematic study of clozapine’s adverse metabolic effects—such as changes in kidney and liver function, body weight, glucose and triglyceride levels, and retinopathy—was conducted. This research investigated how clozapine affects weight, the bodily distribution of chromium, liver damage, fatty liver scores, glucose homeostasis, renal impairment, and retinopathy in mice fed a high fat diet (HFD). We discovered that obese mice treated with clozapine gained more weight and had greater kidney, liver, and retroperitoneal and epididymal fat pad masses; higher daily food efficiency; higher serum or hepatic triglyceride, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and creatinine levels; and higher hepatic lipid regulation marker expression than did the HFD-fed control mice. Furthermore, the clozapine group mice exhibited insulin resistance, poorer insulin sensitivity, greater glucose intolerance, and less Akt phosphorylation; their GLUT4 expression was lower, they had renal damage, more reactive oxygen species, and IL-1 expression, and, finally, their levels of antioxidative enzymes (superoxide dismutase, glutathione peroxidase, and catalase) were lower. Moreover, clozapine reduced the thickness of retinal cell layers and increased iNOS and NF-κB expression; a net negative chromium balance occurred because more chromium was excreted through urine, and this influenced chromium mobilization, which did not help overcome the hyperglycemia. Our clozapine group had considerably higher fatty liver scores, which was supported by the findings of lowered adiponectin protein levels and increased FASN protein, PNPLA3 protein, FABP4 mRNA, and SREBP1 mRNA levels. We conclude that clozapine can worsen nonalcoholic fatty liver disease, diabetes, and kidney and retinal injury. Therefore, long-term administration of clozapine warrants higher attention.
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Affiliation(s)
- Geng-Ruei Chang
- Department of Veterinary Medicine, National Chiayi University, 580 Xinmin Road, Chiayi 600023, Taiwan; (G.-R.C.); (C.-M.W.); (C.-F.W.); (T.-C.L.); (H.-J.L.)
| | - Hsien-Yueh Liu
- Bachelor Degree Program in Animal Healthcare, Hungkuang University, 6 Section, 1018 Taiwan Boulevard, Shalu District, Taichung 433304, Taiwan; (H.-Y.L.); (J.-W.L.); (W.-L.L.)
| | - Wei-Cheng Yang
- School of Veterinary Medicine, National Taiwan University, 4 Section, 1 Roosevelt Road, Taipei 100046, Taiwan;
| | - Chao-Min Wang
- Department of Veterinary Medicine, National Chiayi University, 580 Xinmin Road, Chiayi 600023, Taiwan; (G.-R.C.); (C.-M.W.); (C.-F.W.); (T.-C.L.); (H.-J.L.)
| | - Ching-Fen Wu
- Department of Veterinary Medicine, National Chiayi University, 580 Xinmin Road, Chiayi 600023, Taiwan; (G.-R.C.); (C.-M.W.); (C.-F.W.); (T.-C.L.); (H.-J.L.)
| | - Jen-Wei Lin
- Bachelor Degree Program in Animal Healthcare, Hungkuang University, 6 Section, 1018 Taiwan Boulevard, Shalu District, Taichung 433304, Taiwan; (H.-Y.L.); (J.-W.L.); (W.-L.L.)
| | - Wei-Li Lin
- Bachelor Degree Program in Animal Healthcare, Hungkuang University, 6 Section, 1018 Taiwan Boulevard, Shalu District, Taichung 433304, Taiwan; (H.-Y.L.); (J.-W.L.); (W.-L.L.)
- General Education Center, Chaoyang University of Technology, 168 Jifeng Eastern Road, Taichung 413310, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Asia University Hospital, 222 Fuxin Road, Wufeng District, Taichung 413505, Taiwan;
- Department of Medical Laboratory Science and Biotechnology, Asia University, 500 Lioufeng Road, Wufeng District, Taichung 413305, Taiwan
- Division of Cardiovascular Medicine, China Medical University Hospital, 2 Yude Road, North District, Taichung 404332, Taiwan
- College of Medicine, China Medical University, 91 Hsueh-Shih Road, North District, Taichung 404333, Taiwan
| | - Tzu-Chun Lin
- Department of Veterinary Medicine, National Chiayi University, 580 Xinmin Road, Chiayi 600023, Taiwan; (G.-R.C.); (C.-M.W.); (C.-F.W.); (T.-C.L.); (H.-J.L.)
| | - Huei-Jyuan Liao
- Department of Veterinary Medicine, National Chiayi University, 580 Xinmin Road, Chiayi 600023, Taiwan; (G.-R.C.); (C.-M.W.); (C.-F.W.); (T.-C.L.); (H.-J.L.)
| | - Po-Hsun Hou
- Department of Psychiatry, Taichung Veterans General Hospital, 4 Section, 1650 Taiwan Boulevard, Taichung 407219, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, 2 Section, 155 Linong Street, Beitou District, Taipei 112304, Taiwan
- Correspondence: (P.-H.H.); (C.-H.C.); (C.-F.L.); Tel.: +886-4-23592525 (P.-H.H.); +886-975-617071 (C.-H.C.); +886-8-7703202 (C.-F.L.)
| | - Chee-Hong Chan
- Division of Nephrology, Chang Bing Show Chwan Memorial Hospital, 6 Lugong Road, Lukang Township, Changhua 505029, Taiwan
- Correspondence: (P.-H.H.); (C.-H.C.); (C.-F.L.); Tel.: +886-4-23592525 (P.-H.H.); +886-975-617071 (C.-H.C.); +886-8-7703202 (C.-F.L.)
| | - Chuen-Fu Lin
- Department of Veterinary Medicine, College of Veterinary Medicine, National Pingtung University of Science and Technology, 1 Shuefu Road, Neipu, Pingtung 912301, Taiwan
- Correspondence: (P.-H.H.); (C.-H.C.); (C.-F.L.); Tel.: +886-4-23592525 (P.-H.H.); +886-975-617071 (C.-H.C.); +886-8-7703202 (C.-F.L.)
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Bernardo M, Rico-Villademoros F, García-Rizo C, Rojo R, Gómez-Huelgas R. Real-World Data on the Adverse Metabolic Effects of Second-Generation Antipsychotics and Their Potential Determinants in Adult Patients: A Systematic Review of Population-Based Studies. Adv Ther 2021; 38:2491-2512. [PMID: 33826090 PMCID: PMC8107077 DOI: 10.1007/s12325-021-01689-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/26/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To assess the risk of occurrence and potential determinants of metabolic disorders in adult patients treated with second-generation antipsychotics (SGAs) under real-world practice conditions. METHODS MEDLINE, EMBASE, and PsycInfo were searched in July 2019 from database inception. We included population-based, longitudinal, comparative studies that report the results of the outcomes of interest for adult participants, including diabetes, ketoacidosis, hyperosmolar hyperglycemic state, weight gain/obesity, dyslipidemia, hypertension, and metabolic syndrome. Two reviewers independently extracted data on the study design, study quality, and study outcomes. RESULTS We included 40 studies. Most studies showed that clozapine and olanzapine were associated with an increased likelihood of developing diabetes, while the results for risperidone and quetiapine were mixed. Although less well studied, ziprasidone and aripiprazole appeared to not be associated with the occurrence of diabetes. Information on antipsychotic-induced weight gain/obesity is extremely scarce. Regarding dyslipidemia, aripiprazole was not associated with an increased likelihood of developing dyslipidemia, clozapine was associated with an increased likelihood of developing dyslipidemia, and risperidone, olanzapine, quetiapine, and ziprasidone showed mixed results. Two studies suggested an association between ziprasidone and the occurrence of hypertension. Several studies found that the occurrence of a metabolic disorder acted as a risk factor for the development of other metabolic disorders. We did not find information on brexpiprazole, cariprazine, or lurasidone, and data on any long-acting SGA were lacking. CONCLUSION Although there are relevant differences among SGAs concerning the risk of metabolic disorders, it appears that none of the SGAs included in our review are fully devoid of these disturbances.
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Affiliation(s)
- Miquel Bernardo
- Department of Psychiatry, Hospital Clínic, University of Barcelona, Idibaps, Cibersam, Barcelona, Spain.
| | | | - Clemente García-Rizo
- Department of Psychiatry, Hospital Clínic, University of Barcelona, Idibaps, Cibersam, Barcelona, Spain
| | - Rosa Rojo
- Faculty of Health Sciences, Alfonso X El Sabio University, Villanueva de la Cañada, Madrid, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Department, Instituto de Investigación Biomedica de Malaga-IBIMA, Regional University Hospital of Malaga, Malaga, Spain
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Abstract
PURPOSE/BACKGROUND To evaluate the outcome of diabetes mellitus among patients of schizophrenia who had diabetes mellitus before starting clozapine. METHODS Clozapine data were screened to detect the patients who had diabetes mellitus before starting clozapine. Those who had diabetes mellitus before starting clozapine were taken up for the study. RESULTS Of the 468 records screened, 28 patients (5.6%) had diabetes mellitus before starting clozapine. Among the 28 patients, 15 (53.6%) were females, and 13 (46.4%) were male. In three-fourths (75%) of the patients, clozapine was started while these patients were admitted to the inpatient unit. Twenty-six patients had type 2 diabetes mellitus and 2 patients had type 1 diabetes mellitus at the time of starting clozapine. Most patients also had deranged blood glucose levels at the time of starting clozapine and required close monitoring of blood glucose levels and also starting/continuation of antidiabetic medications. None of the patients developed diabetic ketoacidosis during the initial part of the treatment. At the mean follow-up duration of 16 months, most patients were on regular follow-up for more than 1 year, and their blood glucose levels were maintained close to the reference range. Majority of these patients showed good response to clozapine. CONCLUSIONS The present study suggests that presence of diabetes mellitus should not stop the clinicians to use clozapine among patients with schizophrenia. However, close monitoring of blood glucose levels must be done.
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Yuen JWY, Kim DD, Procyshyn RM, Panenka WJ, Honer WG, Barr AM. A Focused Review of the Metabolic Side-Effects of Clozapine. Front Endocrinol (Lausanne) 2021; 12:609240. [PMID: 33716966 PMCID: PMC7947876 DOI: 10.3389/fendo.2021.609240] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
The second generation antipsychotic drug clozapine represents the most effective pharmacotherapy for treatment-resistant psychosis. It is also associated with low rates of extrapyramidal symptoms and hyperprolactinemia compared to other antipsychotic drugs. However, clozapine tends to be underutilized in clinical practice due to a number of disabling and serious side-effects. These are characterized by a constellation of metabolic side-effects which include dysregulation of glucose, insulin, plasma lipids and body fat. Many patients treated with clozapine go on to develop metabolic syndrome at a higher rate than the general population, which predisposes them for Type 2 diabetes mellitus and cardiovascular disease. Treatments for the metabolic side-effects of clozapine vary in their efficacy. There is also a lack of knowledge about the underlying physiology of how clozapine exerts its metabolic effects in humans. In the current review, we focus on key studies which describe how clozapine affects each of the main symptoms of the metabolic syndrome, and cover some of the treatment options. The clinical data are then discussed in the context of preclinical studies that have been conducted to identify the key biological substrates involved, in order to provide a better integrated overview. Suggestions are provided about key areas for future research to better understand how clozapine causes metabolic dysregulation.
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Affiliation(s)
- Jessica W. Y. Yuen
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David D. Kim
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ric M. Procyshyn
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - William J. Panenka
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - William G. Honer
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M. Barr
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Alasdair M. Barr,
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Buhagiar K, Jabbar F. Association of First- vs. Second-Generation Antipsychotics with Lipid Abnormalities in Individuals with Severe Mental Illness: A Systematic Review and Meta-Analysis. Clin Drug Investig 2019; 39:253-273. [DOI: 10.1007/s40261-019-00751-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Risk of weight gain for specific antipsychotic drugs: a meta-analysis. NPJ SCHIZOPHRENIA 2018; 4:12. [PMID: 29950586 PMCID: PMC6021430 DOI: 10.1038/s41537-018-0053-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 12/04/2022]
Abstract
People with schizophrenia are at considerably higher risk of cardiometabolic morbidity than the general population. Second-generation antipsychotic drugs contribute to that risk partly through their weight gain effects, exacerbating an already high burden of disease. While standard ‘as-randomized’ analyses of clinical trials provide valuable information, they ignore adherence patterns across treatment arms, confounding estimates of realized treatment exposure on outcome. We assess the effect of specific second-generation antipsychotics on weight gain, defined as at least a 7% increase in weight from randomization, using a Bayesian hierarchical model network meta-analysis with individual patient level data. Our data consisted of 14 randomized clinical trials contributing 5923 subjects (mean age = 39 [SD = 12]) assessing various combinations of olanzapine (n = 533), paliperidone (n = 3482), risperidone (n = 540), and placebo (n = 1368). The median time from randomization to dropout or trial completion was 6 weeks (range: 0–60 weeks). The unadjusted probability of weight gain in the placebo group was 4.8% across trials. For each 10 g chlorpromazine equivalent dose increase in olanzapine, the odds of weight gain increased by 5 (95% credible interval: 1.4, 5.3); the effect of risperidone (odds ratio = 1.6 [0.25, 9.1]) was estimated with considerable uncertainty but no different from paliperidone (odds ratio = 1.3 [1.2, 1.5]). People taking a commonly prescribed antipsychotic to treat schizophrenia have an increased risk of weight gain. Sharon-Lise Normand of Harvard Medical School in the US and colleagues analysed data from 14 randomized control trials representing almost 6000 people taking one of three antipsychotic drugs for schizophrenia, or a placebo. Using a unique statistical approach, they found that people taking the drug olanzapine had the highest risk of weight gain. People taking paliperidone had only a small risk, while there was uncertainty regarding the drug riperidone. Antipsychotic drugs can often be taken for decades, so understanding their cummulative effects on patient health is crucial to improving quality of life and preventing premature mortality. The method used in this study is unique and could be used to analyse other aspects of drug use.
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De Berardis D, Rapini G, Olivieri L, Di Nicola D, Tomasetti C, Valchera A, Fornaro M, Di Fabio F, Perna G, Di Nicola M, Serafini G, Carano A, Pompili M, Vellante F, Orsolini L, Martinotti G, Di Giannantonio M. Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine. Ther Adv Drug Saf 2018; 9:237-256. [PMID: 29796248 PMCID: PMC5956953 DOI: 10.1177/2042098618756261] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/10/2018] [Indexed: 12/15/2022] Open
Abstract
Clozapine, a dibenzodiazepine developed in 1961, is a multireceptorial atypical antipsychotic approved for the treatment of resistant schizophrenia. Since its introduction, it has remained the drug of choice in treatment-resistant schizophrenia, despite a wide range of adverse effects, as it is a very effective drug in everyday clinical practice. However, clozapine is not considered as a top-of-the-line treatment because it may often be difficult for some patients to tolerate as some adverse effects can be particularly bothersome (i.e. sedation, weight gain, sialorrhea etc.) and it has some other potentially dangerous and life-threatening side effects (i.e. myocarditis, seizures, agranulocytosis or granulocytopenia, gastrointestinal hypomotility etc.). As poor treatment adherence in patients with resistant schizophrenia may increase the risk of a psychotic relapse, which may further lead to impaired social and cognitive functioning, psychiatric hospitalizations and increased treatment costs, clozapine adverse effects are a common reason for discontinuing this medication. Therefore, every effort should be made to monitor and minimize these adverse effects in order to improve their early detection and management. The aim of this paper is to briefly summarize and provide an update on major clozapine adverse effects, especially focusing on those that are severe and potentially life threatening, even if most of the latter are relatively uncommon.
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Affiliation(s)
- Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, p.zza Italia 1, 64100 Teramo, Italy
| | - Gabriella Rapini
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Luigi Olivieri
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Domenico Di Nicola
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Carmine Tomasetti
- Polyedra Research Group, Teramo, Italy Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Alessandro Valchera
- Polyedra Research Group, Teramo, Italy Villa S. Giuseppe Hospital, Hermanas Hospitalarias, Ascoli Piceno, Italy
| | - Michele Fornaro
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Fabio Di Fabio
- Polyedra Research Group, Teramo, Italy Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Perna
- Hermanas Hospitalarias, FoRiPsi, Department of Clinical Neurosciences, Villa San Benedetto Menni, Albese con Cassano, Como, Italy Department of Psychiatry and Neuropsychology, University of Maastricht, Maastricht, The Netherlands Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, University of Miami, Florida, USA
| | - Marco Di Nicola
- Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Alessandro Carano
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital ‘Madonna Del Soccorso’, San Benedetto del Tronto, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Federica Vellante
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Laura Orsolini
- Polyedra Research Group, Teramo, Italy Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, UK
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
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Tully J, Sim C, Hemani R, Munir M, Khalil N, Fahy S. Audit of monitoring of the parameters of metabolic syndrome in patients on clozapine. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/pb.bp.111.037994] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims and MethodHigh rates of metabolic syndrome exist among patients on clozapine. Monitoring its parameters facilitates interventions which may alleviate negative health consequences. We completed an audit of the monitoring of the parameters of metabolic syndrome in patients on clozapine. The results were compared with the Maudsley Guidelines for monitoring in patients on any antipsychotic medication.ResultsInitial audit showed high overall rates of concordance with guidelines for the frequency of measurement of blood pressure (91.8%), but much lower rates for measuring fasting blood glucose (43.2%) and lipid profile (52.7%), and no record of analysis of waist circumference. This prompted development of a formal protocol for measuring parameters. Repeat audit after 1 year showed marked improvement in rates of measurement.Clinical implicationsImplementation of relatively straightforward measures, such as the introduction of a one-page form on which to record parameters, can lead to a much improved rate of monitoring for metabolic syndrome. This should in turn prompt therapeutic interventions, which are discussed.
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Shaker A, Jones R. Clozapine discontinuation in early schizophrenia: a retrospective case note review of patients under an early intervention service. Ther Adv Psychopharmacol 2018; 8:3-11. [PMID: 29344339 PMCID: PMC5761911 DOI: 10.1177/2045125317741449] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/07/2017] [Indexed: 01/29/2023] Open
Abstract
AIM Research in patients with treatment-resistant schizophrenia has demonstrated that clozapine discontinuation is associated with poor outcomes. There is, however, a paucity of research investigating the impact of clozapine discontinuation specifically in younger patients with more recent onset schizophrenia. A case note review was therefore conducted to ascertain medium-term prognoses in patients with treatment-resistant schizophrenia under an early intervention service (EIS) following clozapine discontinuation. METHODS The case notes of 25 patients under the care of Birmingham EIS who discontinued clozapine were examined retrospectively. Reasons for discontinuation were recorded. Clinical outcomes including total duration of inpatient or home treatment admission, antipsychotic dose, number of alternative antipsychotics prescribed and adverse events were recorded for both the year before and the year after stopping clozapine. Statistical comparisons of pre- and post-discontinuation clinical outcomes determined whether discontinuation had negative effects. RESULTS There was no significant difference between the pre- and post-discontinuation clinical status following clozapine discontinuation. More than half (56%) of patients remained stable after stopping clozapine. Mean inpatient or home treatment stay rose from 29.7 to 62.6 days (p = 0.155), total antipsychotic dose from 50.1% of British National Formulary (BNF) limits to 60.5% (p = 0.627), number of alternative antipsychotics prescribed from 1.28 to 1.80 (p = 0.186), number of hospital/home treatment episodes from 0.20 to 0.44 (p = 0.083) and number of adverse events from 0 to 0.20 (p = 0.059). Non-compliance was the main reason for discontinuation (44%, n = 11). CONCLUSIONS This is the first clozapine discontinuation study specifically considering EIS patients. Discontinuation did not lead to significant effects on 1 year outcomes, though the study is underpowered. These findings may be used to inform future prospective cohort discontinuation studies.
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Affiliation(s)
- Andrew Shaker
- University of Birmingham, Birmingham, West Midlands, UK
| | - Rowena Jones
- Birmingham and Solihull Mental Health NHS Foundation Trust, Old QE Hospital, Birmingham, B1 3RB, UK
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Zhang Y, Liu Y, Su Y, You Y, Ma Y, Yang G, Song Y, Liu X, Wang M, Zhang L, Kou C. The metabolic side effects of 12 antipsychotic drugs used for the treatment of schizophrenia on glucose: a network meta-analysis. BMC Psychiatry 2017; 17:373. [PMID: 29162032 PMCID: PMC5698995 DOI: 10.1186/s12888-017-1539-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/13/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Antipsychotics have serious metabolic side effects on blood glucose. However, the comparative influence of these drugs on blood glucose levels has not been comprehensively evaluated. We conducted a network meta-analysis to create a hierarchy of the side effects of 12 antipsychotic drugs on changes in blood glucose levels. METHODS A systematic search of the PubMed, EMBASE and Cochrane databases (last search June 2016) was conducted to identify studies that reported randomized controlled trials (RCTs) comparing changes in blood glucose levels between patients receiving one of 12 antipsychotic drugs or a placebo for the treatment of schizophrenia or related disorders. The studies we searched were limited to those published in English. Two reviewers independently extracted data. The primary outcome of interest was changes in fasting glucose levels. RESULTS We included 47 studies with 114 relevant arms. Of the antipsychotic drugs, only olanzapine was associated with significantly increased glucose levels compared to a placebo (mean difference (MD) = 3.95, 95% confidence interval (CI) = 0.14 to 7.76). Moreover, olanzapine was associated with a significantly greater change in the glucose levels than ziprasidone (MD = 5.51, 95% CI = 1.62 to 9.39), lurasidone (MD = 5.58, 95% CI = 0.53 to 10.64) or risperidone (MD = 3.05, 95% CI = 0.87 to 5.22). Ziprasidone and lurasidone were associated with minimal glucose changes compared to the other antipsychotics. CONCLUSIONS Olanzapine was associated with a significantly greater change in blood glucose levels than ziprasidone, lurasidone, risperidone or placebo treatment. The application of a hierarchy of glucose metabolism-related side effects may help clinicians tailor the choice of antipsychotic drug to meet the needs of individual patients.
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Affiliation(s)
- Yangyu Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yingyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yingying Su
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yueyue You
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yue Ma
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Guang Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yan Song
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Xinyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Mohan Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Lili Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Changgui Kou
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
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Abstract
Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.
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17
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Time-dependent changes and potential mechanisms of glucose-lipid metabolic disorders associated with chronic clozapine or olanzapine treatment in rats. Sci Rep 2017; 7:2762. [PMID: 28584269 PMCID: PMC5459828 DOI: 10.1038/s41598-017-02884-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/19/2017] [Indexed: 11/16/2022] Open
Abstract
Chronic treatment with second-generation antipsychotic drugs (SGAs) has been associated with an increased risk of metabolic syndrome. To evaluate the longitudinal changes in glucose-lipid homeostasis after SGA use, we studied the time-dependent effects of olanzapine (OLZ) (3 mg/kg, b.i.d.) or clozapine (CLZ) (20 mg/kg, b.i.d.) treatment on metabolic profiles for 9 weeks in rats. Although only OLZ significantly increased body weight in rats, both OLZ and CLZ elevated blood lipid levels. Chronic OLZ treatment induced significant weight gain leading to a higher fasting insulin level and impaired glucose tolerance, whereas CLZ lowered fasting insulin levels and impaired glucose tolerance independent of weight gain. Treatment with both drugs deranged AKT/GSK phosphorylation and up-regulated muscarinic M3 receptors in the rats’ livers. Consistent with an elevation in lipid levels, both OLZ and CLZ significantly increased the protein levels of nuclear sterol regulatory element-binding proteins (SREBPs) in the liver, which was associated with improvement in hepatic histamine H1R. However, enhanced carbohydrate response element binding protein (ChREBP) signalling was observed in only CLZ-treated rats. These results suggest that SGA-induced glucose-lipid metabolic disturbances could be independent of weight gain, possibly through activation of SREBP/ChREBP in the liver.
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Silva Gracia M, Köppl A, Unholzer S, Haen E. Development and validation of an HPLC-UV method for the simultaneous determination of the antipsychotics clozapine, olanzapine and quetiapine, several beta-blockers and their metabolites. Biomed Chromatogr 2017; 31. [PMID: 28266722 DOI: 10.1002/bmc.3968] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/22/2017] [Accepted: 03/03/2017] [Indexed: 11/12/2022]
Abstract
A simple, accurate and selective column-switching high-performance liquid chromatography (HPLC) method was developed and validated for simultaneous quantification of six beta-blockers (metoprolol, timolol, bisoprolol, propranolol, carvedilol and nebivolol), three of their metabolites (α-hydroxy metoprolol, N-desisopropyl propranolol and 4'-hydroxy carvedilol 4-HCAR), three antipsychotics (olanzapine, clozapine and quetiapine) and three of their metabolites (N-desmethyl olanzapine, N-desmethyl clozapine and N-desalkyl quetiapine) in human serum. After pretreatment on a Merck LiChrospher RP-4 ADS column (25 μm), drugs were separated on a Phenomenex Gemini Phenyl Hexyl 110 A column (250 × 4.6 mm, 5 μm) using a gradient mixture of acetonitrile and potassium dihydrogen phosphate buffer pH 3.1 (containing 10% methanol) as a mobile phase at a flow rate of 1 mL/min. The total analysis time was 40 min. For detection of the analytes, four different UV wavelengths were used: 215, 226, 242 and 299 nm. The method was validated according to the guidelines of the Society of Toxicology and Forensic Chemistry in terms of selectivity, linearity, accuracy, precision and stability and successfully applied for the analysis of the 15 described analytes in human serum.
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Affiliation(s)
- Margarete Silva Gracia
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Alexandra Köppl
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Sandra Unholzer
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
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Grover S, Sahoo S, Mahajan S. Clozapine-induced hypertension: A case report and review of literature. Ind Psychiatry J 2017; 26:103-105. [PMID: 29456332 PMCID: PMC5810158 DOI: 10.4103/ipj.ipj_9_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
There are very few reports which suggest an association between clozapine and hypertension. We report a case in which a direct link of initiation of clozapine to development of hypertension which required pharmacological intervention. A 32-year-old male who did not have any history of hypertension and had normal blood pressure at the baseline developed high blood pressure (i.e., 150/90 mmHg) while on clozapine 100 mg/day. Reduction of the dose of clozapine to 75 mg/day led to the return of blood pressure to baseline, with increase in blood pressure to 150/90 mmHg on increasing the dose of clozapine again, requiring tablet atenolol 50 mg/day for normalization of blood pressure with concomitant continuation of atenolol. Later, clozapine was increased to 350 mg/day, with no recurrence of raise in blood pressure. After 6 months, tablet atenolol was stopped with no evidence of hypertension in follow-up. To conclude, this case report suggests that clozapine can rarely lead to hypertension during the initial phase of treatment.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Swapnajeet Sahoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sonali Mahajan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Citrome LL, Holt RIG, Zachry WM, Clewell JD, Orth PA, Karagianis JL, Hoffmann VP. Risk of Treatment-Emergent Diabetes Mellitus in Patients Receiving Antipsychotics. Ann Pharmacother 2016; 41:1593-603. [PMID: 17785613 DOI: 10.1345/aph.1k141] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Type 2 diabetes mellitus has been reported during antipsychotic treatment. Objective: To quantify the potential risk of treatment-emergent diabetes mellitus among patients receiving antipsychotic medications. Methods: The MEDLINE and Psychinfo databases were searched using the key words antipsychotic (including individual drug names), diabetes, risk, and incidence for all English-language articles published between 1966 and 2005. Risk calculations were performed using data obtained from pharmacoepidemiologic studies that met the following criteria: (1) cohort design, (2) determination of preexisting diabetes, (3) inclusion of antipsychotic monotherapy as an exposure variable, and (4) comparison with exposure to first-generation antipsychotics. Studies meeting these criteria were used to calculate incidence, attributable risk between agents, and number needed to harm. Results: A total of 25 observational pharmacoepidemiologic studies were found comparing antipsychotics on the outcome of diabetes mellitus. Sufficient information was provided in 15 of the reports to be able to estimate attributable risk, Attributable risk for individual second-generation antipsychotics relative to first-generation antipsychotics ranged from 53 more to 46 fewer new cases of diabetes per 1000 patients. Little observable difference was noted between the individual second-generation antipsychotics versus first-generation antipsychotics on this outcome. However, few of the studies controlled for body weight, race or ethnicity, or the presence of diabetogenic medications. None adjusted for familial history of diabetes, levels of physical activity, or diet, as this information is not usually available in the databases used in pharmacoepidemiologic studies. Conclusions: Based on the published pharmacoepidemiologic reports reviewed, the avoidance of diabetes as an outcome cannot be predictably achieved with precision by choice of a second- versus a first-generation antipsychotic. Risk management for new-onset diabetes requires the assessment of established risk factors such as family history, advancing age, non-white ethnicity, diet, central obesity, and level of physical activity.
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Affiliation(s)
- Leslie L Citrome
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA.
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Cetin M. Clozaphobia: Fear of Prescribers of Clozapine for Treatment of Schizophrenia. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20141223052008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Mesut Cetin
- Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Pychopharmacology, GATA Haydarpasa Training Hospital, Department of Psychiatry, Istanbul-Turkey
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Rekhi G, Khyne TT, Lee J. Estimating 10-year cardiovascular disease risk in Asian patients with schizophrenia. Gen Hosp Psychiatry 2016; 43:46-50. [PMID: 27796257 DOI: 10.1016/j.genhosppsych.2016.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study aims to describe the cardiovascular risk profile of Asian patients with schizophrenia. METHODS Data was extracted from the databases of 139 patients with schizophrenia and 206 controls from two previous studies conducted at the Institute for Mental Health (IMH), Singapore. Their medical and smoking histories were obtained, and anthropometric parameters measured. Framingham risk score (FRS) calculator using body mass index was used to compute the 10-year cardiovascular disease risk (FRSBMI) and the vascular age (VABMI) for each participant. Data on fasting lipids were available for 80 patients and all the controls; hence the FRS for lipids (FRSlipids) and VA (VAlipids) were also computed. The difference between VA and actual age was computed as VAdiff. RESULTS The 10-year CVD risk and VAdiff based on lipids as well as BMI were significantly higher for patients compared to controls (all p<0.01). There was a strong correlation between FRSlipids and FRSBMI (r=0.97, p<0.001). Significantly higher numbers of patients than controls were smokers and obese; and reported having dyslipidaemia. CONCLUSIONS We found a high risk of CVD in patients with schizophrenia as compared to controls; and conclude that patients with schizophrenia need regular physical health monitoring, especially for cardiovascular risk factors.
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Affiliation(s)
- Gurpreet Rekhi
- Research Division, Institute of Mental Health, 10 Buangkok View, Singapore 539747, Singapore.
| | - Toe Toe Khyne
- Research Division, Institute of Mental Health, 10 Buangkok View, Singapore 539747, Singapore
| | - Jimmy Lee
- Research Division, Institute of Mental Health, 10 Buangkok View, Singapore 539747, Singapore; Department of General Psychiatry 1, Institute of Mental Health, 10 Buangkok View, Singapore 539747, Singapore; Office of Clinical Sciences, Duke-National University of Singapore Graduate Medical School, 8 College Road, Singapore 169857, Singapore
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Hepburn K, Brzozowska MM. Diabetic ketoacidosis and severe hypertriglyceridaemia as a consequence of an atypical antipsychotic agent. BMJ Case Rep 2016; 2016:bcr-2016-215413. [PMID: 27507689 DOI: 10.1136/bcr-2016-215413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The atypical antipsychotic agent clozapine, although an effective treatment for schizophrenia, is linked with metabolic adverse effects. We report a case of diabetic ketoacidosis and very severe hypertriglyceridaemia associated with clozapine use, in a patient with type 2 diabetes mellitus, who was successfully treated with continuous insulin infusion and fluids. As clozapine proved to be the most efficacious in controlling the patient's psychotic symptoms, the patient has been continued on clozapine despite its known metabolic side effects. Importantly the patient has achieved satisfactory long-term lipid and glycaemic control. The current recommendations related to the metabolic care for patients treated with atypical antipsychotic agents as well as the mechanisms behind abnormal glucose and lipid regulation with clozapine therapy are discussed.
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Affiliation(s)
- Kirsten Hepburn
- Endocrinology Department, Sutherland Hospital, Caringbah, New South Wales, Australia
| | - Malgorzata Monika Brzozowska
- Endocrinology Department, Sutherland Hospital, Caringbah, New South Wales, Australia St George & Sutherland Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Suehs BT, Bettinger TL, Hall CS. Atypical Antipsychotics and Diabetes: Discussion and Monitoring Recommendations. J Pharm Technol 2016. [DOI: 10.1177/875512250502100103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective:To discuss the relationship between atypical antipsychotics (AAPs) and diabetes and to report new monitoring recommendations for patients being prescribed AAPs.Data Sources:Articles were identified through searches of MEDLINE and PubMed (1966–March 2004). Search terms included hyperglycemia, diabetes, glucose, atypical antipsychotics, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Only articles published in the English language were included in the search. Additionally, bibliographies of articles cited were used to identify additional articles.Study Selection and Data Extraction:All available articles identified by the data sources were reviewed and those deemed relevant to the review were included.Data Synthesis:Information pertaining to diabetes/hyperglycemia risk in case reports and submissions to the Medwatch system prompted the FDA to require labeling changes for all AAPs. The exact relationship between AAPs and diabetes remains unclear. The association is clouded by the fact that patients with schizophrenia are, in general, at higher risk for diabetes mellitus. Sedentary lifestyle and poor dietary intake are 2 possible contributing causes of diabetes in patients with schizophrenia. Weight gain or other metabolic effects of AAPs may put patients at further risk of developing diabetes. The American Diabetes Association, American Psychiatric Association, American Association of Clinical Epidemiologists, and North American Association for the Study of Obesity have released a joint consensus statement addressing some of the concerns related to AAP use.Conclusions:Because of the apparent increased risk of diabetes in patients taking AAPs, monitoring weight, fasting blood glucose, blood pressure, and lipids should be a part of the baseline assessment and ongoing care.
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Affiliation(s)
- Brandon T Suehs
- BRANDON T SUEHS PharmD, Psychiatric Pharmacy Practice Resident, College of Pharmacy, The University of Texas at Austin, Austin, TX
| | - Tawny L Bettinger
- TAWNY L BETTINGER PharmD BCPP, Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, The University of Texas at Austin
| | - Catherine S Hall
- CATHERINE S HALL PharmD BCPP, Clinical Pharmacist, Bluebonnet Trails Community Mental Health Center, Seguin, TX
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Shakeri J, Karimi K, Farnia V, Golshani S, Alikhani M. Prevalence of Metabolic Syndrome in Patients with Schizophrenia Referred to Farabi Hospital, Kermanshah, Iran. Oman Med J 2016; 31:270-5. [PMID: 27403239 DOI: 10.5001/omj.2016.53] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Our study was conducted to determine the prevalence of metabolic syndrome in patients with schizophrenia. METHODS The study population included all patients with schizophrenia who were referred to Farabi Hospital, Kermanshah, Iran, between March 2014 and March 2015. A total of 280 subjects who met the study criteria were selected according to the census sampling method. RESULTS The prevalence of metabolic syndrome was 30.4% (20.7% in men and 51.5% in women). The prevalence of metabolic syndrome was greater in patients > 40 years than patients aged 20-40 years. There was a significant relationship between marital status and number of hospitalizations with the prevalence of metabolic syndrome. CONCLUSIONS Given the high prevalence of metabolic syndrome in patients with schizophrenia, healthcare professionals should take measures to identify the risk factors and timely treatment of affected patients, thereby improving the patient's quality of life and reducing health costs.
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Affiliation(s)
- Jalal Shakeri
- Department of Psychiatry, Substance abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kamyar Karimi
- Department of Psychiatry, Substance abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Vahid Farnia
- Department of Psychiatry, Substance abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Senobar Golshani
- Department of Psychiatry, Substance abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mostafa Alikhani
- Department of Psychiatry, Substance abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Polcwiartek C, Kragholm K, Schjerning O, Graff C, Nielsen J. Cardiovascular safety of antipsychotics: a clinical overview. Expert Opin Drug Saf 2016; 15:679-88. [DOI: 10.1517/14740338.2016.1161021] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Christoffer Polcwiartek
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kristian Kragholm
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole Schjerning
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jimmi Nielsen
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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No change of the lipid profile under the control of ApoE gene polymorphism in schizophrenics under paliperidone treatment. Psychiatr Q 2014; 85:487-96. [PMID: 25085446 DOI: 10.1007/s11126-014-9309-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The present study tried to explore the effects of Paliperidone on the lipid profiles of schizophrenia patients. One hundred twenty-nine subjects diagnosed with schizophrenia were enrolled into this study and completed the lipid profile evaluation. Their blood samples were obtained on the morning following a 12-hours fast. Cholesterol and triglyceride (TG) levels in plasma were determined, and lipoproteins were determined by enzymatic methods. All participants provided written informed consent, and underwent additional venous blood withdrawal for DNA extraction for genetic study of the ApoE gene polymorphism. Under T test, TC, TG and HDL levels all declined after Paliperidone treatment although with no statistically significant difference. The ratios of TC/HDL declined after Paliperidone treatment, but without statistically significant difference. After GEE-I analysis, we found that ApoE4 genotype (β = 34.471; p < 0.001) had a positive effect on the total cholesterol (TC) level; female had positive effect on the high-density lipoprotein (HDL) level (β = 15.361; p = 0.003); and age had a positive effect on the TG level (β = 1.317; p = 0.030). Smoking (β = 0.961; p = 0.016) had a positive effect on the ratio of TC/HDL change. Lipid profiles were not increased after Paliperidone treatment under the control of ApoE gene polymorphism.
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Wysokiński A. Blood levels of glucose and insulin and insulin resistance in patients with schizophrenia on clozapine monotherapy. Diabetes Metab Syndr 2014; 8:236-241. [PMID: 25311817 DOI: 10.1016/j.dsx.2014.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We tested the hypothesis that fasting blood glucose and insulin levels are higher in schizophrenic subjects on clozapine monotherapy compared with healthy controls and they correlate with anthropometric measurements, laboratory tests and body composition. METHODS Data for 24 subjects with schizophrenia treated with clozapine and 24 age- and sex-matched healthy volunteers was analyzed. RESULTS Patients taking clozapine had higher fasting levels of glucose (103.5±31.6 vs. 87.8±11.7mg/dL, z=-2.03, p=0.04), there was no difference for insulin concentrations and markers of insulin resistance. In the clozapine group glucose levels correlated with clozapine dose (R=-0.43, p=0.03), while insulin levels correlated with weight (R=0.66, p<0.001), body mass index (R=0.54, p=0.007), abdominal (R=0.53, p=0.007) and waist (R=0.43, p=0.04) circumference, total body fat (R=0.51, p=0.01), and uric acid levels (R=0.50, p=0.01). In the clozapine group insulin levels were lower in subjects with body mass index <25kg/m(2) (7.0±3.3 vs. 13.4±8.8μU/mL, p=0.04) and in subjects without abdominal obesity (6.3±2.4 vs. 13.3±8.6μU/mL, p=0.03). CONCLUSIONS We found higher blood glucose levels in subjects taking clozapine and no differences in blood insulin levels between subjects with schizophrenia and controls. Associations between blood insulin levels and abdominal/waist circumferences support the role of abdominal obesity as an important risk factor of insulin resistance.
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Affiliation(s)
- Adam Wysokiński
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Czechosłowacka 8/10, 92-216 Łódź, Poland.
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Abstract
The pharmacological choices for the treatment of schizophrenia have been greatly expanded with the availability of the atypical compounds clozapine (Clozaril, Novartis), risperidone (Risperdal, Janssen-Cilag), olanzapine (Zyprexa, Eli Lilly & Co.), quetiapine (Seroquel, AstraZeneca), ziprasidone (Geodon, Pfizer Inc.) and aripiprazole (Abilify, Otsuka Pharmaceutical Co. Ltd). In this article, the effects of the newer antipsychotics and their side effects are reviewed. Key issues in acute and maintenance treatment, often lifelong, will be reviewed. Side-effect management to ensure adherence to an optimal treatment regimen will be discussed. Coexisting syndromes must be treated in concordance with the patient's clinical presentation. For treatment-resistant patients, atypical compounds are generally more effective than their typical counterparts but medication augmentation strategies are frequently recommended. Finally, the results of recent meta-analyses comparing the effects of atypical versus typical compounds will be critically reviewed and remaining gaps in the current pharmacotherapy of schizophrenia will be explored.
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Affiliation(s)
- J P Lindenmayer
- Psychopharmacology Research Unit, Manhattan Psychiatric Center, Wards Island, NY 10035, USA.
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31
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Citrome L, Volavka J. Atypical antipsychotics: revolutionary or incremental advance? Expert Rev Neurother 2014; 2:69-88. [DOI: 10.1586/14737175.2.1.69] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Otte C, Naber D. Atypical antipsychotics in the treatment of schizophrenic patients. Expert Rev Neurother 2014; 2:355-62. [DOI: 10.1586/14737175.2.3.355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Brooks JM, Tang Y, Chapman CG, Cook EA, Chrischilles EA. What is the effect of area size when using local area practice style as an instrument? J Clin Epidemiol 2013; 66:S69-83. [PMID: 23849157 DOI: 10.1016/j.jclinepi.2013.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 03/06/2013] [Accepted: 04/08/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Discuss the tradeoffs inherent in choosing a local area size when using a measure of local area practice style as an instrument in instrumental variable estimation when assessing treatment effectiveness. STUDY DESIGN Assess the effectiveness of angiotensin converting-enzyme inhibitors and angiotensin receptor blockers on survival after acute myocardial infarction for Medicare beneficiaries using practice style instruments based on different-sized local areas around patients. We contrasted treatment effect estimates using different local area sizes in terms of the strength of the relationship between local area practice styles and individual patient treatment choices; and indirect assessments of the assumption violations. RESULTS Using smaller local areas to measure practice styles exploits more treatment variation and results in smaller standard errors. However, if treatment effects are heterogeneous, the use of smaller local areas may increase the risk that local practice style measures are dominated by differences in average treatment effectiveness across areas and bias results toward greater effectiveness. CONCLUSION Local area practice style measures can be useful instruments in instrumental variable analysis, but the use of smaller local area sizes to generate greater treatment variation may result in treatment effect estimates that are biased toward higher effectiveness. Assessment of whether ecological bias can be mitigated by changing local area size requires the use of outside data sources.
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Affiliation(s)
- John M Brooks
- University of Iowa, College of Pharmacy and College of Public Health, S-515 Pharmacy Bldg., 115 S. Grand Ave, Iowa City, IA 52242, USA.
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Lang DJ, Barr AM, Procyshyn RM. Management of Medication-Related Cardiometabolic Risk in Patients with Severe Mental Illness. CURRENT CARDIOVASCULAR RISK REPORTS 2013; 7:283-287. [PMID: 23864926 PMCID: PMC3702958 DOI: 10.1007/s12170-013-0321-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Severe psychotic disorders, which on their own may be a risk factor for metabolic disorder and cardiovascular illness, are clinically compounded by the significant adverse side effects of antipsychotic medications. The majority of patients with severe psychotic disorders (i.e., schizophrenia, bipolar disorder, mania, and depression) must take antipsychotic medications to treat their psychoses and, subsequently, will require efficacious interventions to manage the metabolic consequences of pharmacologic treatment to mitigate excessive mortality associated with cardiovascular illness. We have reviewed the metabolic consequences of antipsychotic treatment and discussed pilot findings from a new nonpharmacologic intervention study looking at the clinical benefits of regular exercise as a management tool for the cardiometabolic risk factors in a cohort with severe mental illness.
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Affiliation(s)
- Donna J. Lang
- Department of Radiology, University of British Columbia, Centre for Complex Disorders, British Columbia Mental Health and Addictions Research Institute, CFRI Bldg, Rm. 3A-124, 938 West 28th Ave, BC Children’s Hospital Site, Vancouver, BC Canada V5Z 4H4
| | - Alasdair M. Barr
- Department of Pharmacology, British Columbia Mental Health and Addictions Research Institute, Vancouver, BC Canada V5Z 4H4
| | - Ric M. Procyshyn
- Department of Psychiatry, British Columbia Mental Health and Addictions Research Institute, Vancouver, BC Canada V5Z 4H4
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Abstract
Clozapine is the most effective antipsychotic medication for treatment-refractory schizophrenia and is also approved for suicidality in schizophrenia patients. However, it can cause significant medical morbidity and requires intensive medical monitoring once prescribed. Perhaps due to lack of familiarity with its use, it is underused in clinical practice and its initiation often delayed. This article reviews the literature on clozapine in order to measure its potential effectiveness against its adverse effects and ultimately aims to serve as a useful summary for clinicians in their everyday prescribing.
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Affiliation(s)
- Michele Hill
- MGH Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Meltzer HY. Clozapine: balancing safety with superior antipsychotic efficacy. ACTA ACUST UNITED AC 2012; 6:134-44. [PMID: 23006238 DOI: 10.3371/csrp.6.3.5] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clozapine is often referred to as the gold standard for the treatment of schizophrenia and yet has also been described as the most underutilized treatment for schizophrenia supported by solid evidence-based medicine. In 2008, it was used to treat only 4.4% of patients with schizophrenia in the U.S., which is ~10-20% of those with approved indications for clozapine for which there is no alternative of equal efficacy. Its use is much higher in Scandinavian countries and China. The primary indications for clozapine are: 1) treatment-resistant schizophrenia or schizoaffective disorder, defined as persistent moderate to severe delusions or hallucinations despite two or more clinical trials with other antipsychotic drugs; and, 2) patients with schizophrenia or schizoaffective disorder who are at high risk for suicide. Concerns over a number of safety considerations are responsible for much of the underutilization of clozapine: 1) agranulocytosis; 2) metabolic side effects; and, 3) myocarditis. These side effects can be detected, prevented, minimized and treated, but there will be a very small number of fatalities. Nevertheless, clozapine has been found in two large epidemiologic studies to have the lowest mortality of any antipsychotic drug, mainly due to its very large effect to reduce the risk for suicide. Other reasons for limited use of clozapine include the extra effort entailed in monitoring white blood cell counts to detect granulocytopenia or agranulocytosis and, possibly, minimal efforts to market it now that it is largely generic. Awareness of the benefits and risks of clozapine is essential for increasing the use of this lifesaving agent.
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Affiliation(s)
- Herbert Y Meltzer
- Northwestern Feinberg School of Medicine, Ward Building-12-104, 303 East Chicago Avenue, Chicago, IL 60611, USA.
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37
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Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. ACTA ACUST UNITED AC 2012; 12:362-8. [PMID: 14981231 DOI: 10.1038/oby.2004.46] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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38
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Cardiovascular side-effects of antipsychotic drugs: The role of the autonomic nervous system. Pharmacol Ther 2012; 135:113-22. [DOI: 10.1016/j.pharmthera.2012.04.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/08/2012] [Indexed: 01/27/2023]
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Bowblis JR, Crystal S, Intrator O, Lucas JA. Response to regulatory stringency: the case of antipsychotic medication use in nursing homes. HEALTH ECONOMICS 2012; 21:977-993. [PMID: 21882284 DOI: 10.1002/hec.1775] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 05/15/2011] [Accepted: 06/14/2011] [Indexed: 05/31/2023]
Abstract
This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that the use of antipsychotics by nursing homes is responsive to state regulatory enforcement in a manner consistent with the multitasking incentive problem. Specifically, the effect of the regulations is dependent on the degree of complementarity between the regulatory deficiency and the use of antipsychotics.
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Affiliation(s)
- John R Bowblis
- Department of Economics and Scripps Gerontology Center, Miami University, Oxford, OH 45056, USA.
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Hsu JH, Chien IC, Lin CH, Chou YJ, Chou P. Hyperlipidemia in patients with schizophrenia: a national population-based study. Gen Hosp Psychiatry 2012; 34:360-7. [PMID: 22460002 DOI: 10.1016/j.genhosppsych.2012.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 02/07/2012] [Accepted: 02/07/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective was to examine hyperlipidemia among Taiwanese patients with schizophrenia. METHODS We obtained a random sample of 766,427 subjects aged ≥18 years in 2005. Subjects with at least one primary diagnosis of schizophrenia and with a primary or secondary diagnosis of hyperlipidemia or medication for hyperlipidemia were identified. We compared the prevalence and incidence of hyperlipidemia in schizophrenic patients with the general population. RESULTS The prevalence of hyperlipidemia in patients with schizophrenia was higher than that in the general population (8.15% vs. 8.10%; odds ratio 1.17; 95% confidence interval, 1.04-1.31) in 2005. Compared with the general population, schizophrenic patients had a higher prevalence of hyperlipidemia in individuals aged <50 years, among those with higher insurance amount, and among persons living in northern and central regions and in urban areas. The average annual incidence of hyperlipidemia in schizophrenic patients with second-generation antipsychotic use from 2006 to 2008 was higher than that in the general population (1.57% vs. 1.29%; odds ratio 1.31; 95% confidence interval, 1.11-1.55). CONCLUSIONS Patients with schizophrenia had a much higher prevalence of hyperlipidemia in young adulthood than that in the general population. Schizophrenic patients with second-generation antipsychotic exposure had a higher incidence of hyperlipidemia than individuals in the general population.
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Affiliation(s)
- Jer-Hwa Hsu
- Chia-Yi Hospital, Department of Health, Chiayi, Taiwan
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Zhang R, Hao W, Pan M, Wang C, Zhang X, Chen DC, Xiu MH, Yang FD, Kosten TR, Zhang XY. The prevalence and clinical-demographic correlates of diabetes mellitus in chronic schizophrenic patients receiving clozapine. Hum Psychopharmacol 2011; 26:392-6. [PMID: 21826737 DOI: 10.1002/hup.1220] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 05/31/2011] [Accepted: 06/09/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the prevalence and correlates of diabetes in a large sample of Chinese patients with schizophrenia on long-term clozapine treatment, because this population previously has received little systematic study. METHODS Two hundred and six inpatients meeting Diagnostic and Statistical Manual of Mental Disorders, 4th Edition schizophrenia criteria were recruited in a cross-sectional naturalistic study, and compared with 615 healthy control subjects matched for age, sex, education, and body mass index (BMI). The patient's psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). Diagnoses of diabetes were established through review of medical records and fasting blood glucose testing, or an oral glucose tolerance test. RESULTS Diabetes mellitus was more common in patients than in the normal controls (22.3% vs 6.2%) (odds ratio = 4.37, confidence interval (CI) 2.76-6.92, p < 0.001). The prevalence of diabetes increased with age across five age-groups as compared with normal controls (X(2) = 18.0, df = 4, p = 0.001). The PANSS total score and sub-scores showed no differences between the diabetic and non-diabetic groups. Logistic regression in the patients revealed significant associations between diabetes and a family history of diabetes (p < 0.001), age (p < 0.01), and BMI (p < 0.05). CONCLUSION Long-term clozapine treatment was associated with an increased and clinically important risk of diabetes mellitus in Chinese chronic schizophrenic patients, which is consistent with previous reports in Western populations.
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Affiliation(s)
- Ruiling Zhang
- 2nd Hospital affiliated to Xinxiang Medical University, Xinxiang City, Henan Province, China
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Hardy TA, Henry RR, Forrester TD, Kryzhanovskaya LA, Campbell GM, Marks DM, Mudaliar S. Impact of olanzapine or risperidone treatment on insulin sensitivity in schizophrenia or schizoaffective disorder. Diabetes Obes Metab 2011; 13:726-35. [PMID: 21435142 DOI: 10.1111/j.1463-1326.2011.01398.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To assess changes in insulin sensitivity in non-diabetic adults with schizophrenia or schizoaffective disorder treated with olanzapine or risperidone. METHODS One hundred and thirty patients were randomly assigned to 12 weeks double-blind treatment with olanzapine or risperidone. Insulin sensitivity was measured using a two-step euglycaemic, hyperinsulinaemic clamp procedure. Whole-body adiposity was measured using dual-energy X-ray absorptiometry. The primary endpoint was the within-group change from baseline in insulin sensitivity normalized to fat-free mass (M(ffm) /I) during the clamp procedure's low-insulin phase, using an analysis of covariance model including the covariate weight change. RESULTS Forty-one olanzapine-treated and 33 risperidone-treated patients completed baseline and endpoint clamp measurements. Mean M(ffm) /I during the low-insulin phase declined 9.0% (p = 0.226) in olanzapine-treated patients and 13.2% (p = 0.047) in risperidone-treated patients (between-group difference p = 0.354). During the high-insulin phase, M(ffm) /I declined 10.4% (p = 0.036) in olanzapine-treated patients and 2.1% (p = 0.698) in risperidone-treated patients (between-group difference p = 0.664). Changes in M(ffm) /I correlated inversely with changes in body weight and adiposity, which were generally higher in olanzapine-treated patients. Significant within-group increases in fasting glucose, but not haemoglobin A1c (HbA1c), were observed during olanzapine treatment. The fasting glucose change was not correlated with M(ffm) /I changes. CONCLUSIONS Small, but statistically significant, decrements in insulin sensitivity were observed in olanzapine- and risperidone-treated patients at 1 of 2 insulin doses tested. Significant increases in fasting glucose and insulin and total fat mass were observed only in olanzapine-treated patients. Changes in insulin sensitivity correlated significantly with changes in weight or adiposity, but not with changes in glucose.
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Affiliation(s)
- T A Hardy
- Lilly Research Laboratories, Indianapolis, IN, USA.
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Jerrell JM, McIntyre RS, Tripathi A. Incidence and costs of cardiometabolic conditions in patients with schizophrenia treated with antipsychotic medications. ACTA ACUST UNITED AC 2010; 4:161-8. [PMID: 20880826 DOI: 10.3371/csrp.4.3.2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To examine the incidence of cardiometabolic conditions and change in care costs for patients with schizophrenia treated with antipsychotic medications, medical and pharmacy claims from the South Carolina Medicaid program were used to compare the incidence rates for five cardiometabolic conditions in 2,231 patients with schizophrenia who were newly prescribed one of seven antipsychotic medications, using a retrospective cohort design spanning three years. Incidence and cumulative prevalence (pre-existing + incident) rates for the five cardiometabolic conditions were: 10%/23.3% for Type II diabetes mellitus, 7%/13.3% for obesity/excessive weight gain, 17%/20.9% for dyslipidemia, 4.5%/7.3% for high blood pressure, and 15.6%/41.8% for hypertension. After being treated with the antipsychotic medications examined, the odds of developing obesity/excessive weight gain, Type II diabetes mellitus, or dyslipidemia were not significantly related to any specific atypical agent compared to haloperidol. Incidence rates for elevated blood pressure and clinically diagnosed hypertension were higher for patients prescribed ziprasidone (Odds Ratio [OR]=2.41, Confidence Intervals [CI]=1.20-4.85; OR=1.83, CI=1.16-2.90, respectively) relative to those prescribed haloperidol. Cost results indicate significant differences over time in medical service and pharmacy costs in the group which developed incident cardiometabolic conditions. Individuals diagnosed with schizophrenia with moderate prevalence and incidence rates for these cardiometabolic conditions demonstrated substantially decreasing medical care costs over the three years examined, perhaps indicating a widening gap in access to needed services for conditions that are known mortality risk factors.
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Affiliation(s)
- Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
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Abstract
PURPOSE OF REVIEW Schizophrenia is associated with increased mortality and reduced life expectancy, with cardiovascular disease being the most frequent cause of death. Antipsychotics have detrimental effects on different risk factors for cardiovascular disease. This review will focus on the relationship between antipsychotic treatment and cardiovascular disease. RECENT FINDINGS The increased overall mortality and mortality from cardiovascular disease in schizophrenia are now well documented. Patients with schizophrenia are at risk of receiving less optimal treatment for cardiovascular disease. Patients with schizophrenia are at high risk of metabolic syndrome, a cluster of risk factors for cardiovascular disease. Some antipsychotics, in particular, clozapine and olanzapine, frequently cause weight gain, dyslipidemia and diabetes mellitus. Antipsychotics differ in their effects on body weight, lipids and glucose regulation. However, the long-term effects of these differences between individual antipsychotics on overall mortality and cardiovascular mortality are not well established. SUMMARY More research is needed to better understand the relationship between schizophrenia, antipsychotic treatment and cardiovascular disease. More effective treatment strategies need to be developed to reduce the burden of cardiovascular disease in schizophrenia.
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Woo YS, Kim W, Chae JH, Yoon BH, Bahk WM. Blood pressure changes during clozapine or olanzapine treatment in Korean schizophrenic patients. World J Biol Psychiatry 2010; 10:420-5. [PMID: 18609444 DOI: 10.1080/15622970801910399] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Numerous reports have linked atypical antipsychotics, especially clozapine and olanzapine, to the development of cardiovascular risk factors. In this retrospective chart review study, we investigated the blood pressure changes in Korean schizophrenic inpatients treated with clozapine or olanzapine. METHOD We reviewed the medical record of schizophrenic patients treated with clozapine or olanzapine for 8 weeks. A total of 167 patients were included in the study; 70 patients in clozapine group and 97 patients in olanzapine group. Systolic and diastolic blood pressures prior to medication and at post-treatment (8-week) were assessed, and changes in blood pressure were analyzed. The prevalence of hypertension at the time of study period was assessed and compared between the two groups. RESULTS There was a significant difference in hypertension prevalence in comparisons between the clozapine and olanzapine group. The systolic and diastolic blood pressures in the clozapine group were significantly increased after treatment, but systolic and diastolic blood pressures in olanzapine group did not change significantly. CONCLUSION Our findings suggest that clozapine treatment may be associated with increased blood pressure and higher prevalence of hypertension, which may have a significant impact on medical morbidity and mortality.
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Affiliation(s)
- Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Yood MU, DeLorenze G, Quesenberry CP, Oliveria SA, Tsai AL, Willey VJ, McQuade R, Newcomer J, L'Italien G. The incidence of diabetes in atypical antipsychotic users differs according to agent--results from a multisite epidemiologic study. Pharmacoepidemiol Drug Saf 2009; 18:791-9. [PMID: 19526626 DOI: 10.1002/pds.1781] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE The purpose of this study was to examine the association between atypical antipsychotics, including the newer agents, aripiprazole and ziprasidone, and newly treated diabetes, using the largest post-marketing cohort of patients exposed to these newer treatments that has been studied to date. METHODS Identified two overlapping cohorts-a simple cohort (all antipsychotic users) and an inception cohort (new users of antipsychotics)-using automated data from three United States sites (60.4 million covered lives). Patients exposed to antipsychotics > or = 45 days were identified and followed for incident diagnoses of treated diabetes. Data analysis accounted for drug switching and non-consistent drug use. RESULTS In the 55 287-member inception cohort, 357 cases of newly treated diabetes were identified. Compared with current use of typical antipsychotics, current users of aripiprazole (adjusted hazard ratio (aHR) 0.93, 95% confidence interval (CI) 0.50-1.76), quetiapine (aHR 1.04, 95%CI, 0.67-1.62), risperidone (aHR 0.85, 95%CI, 0.54-1.36) and ziprasidone (aHR 1.05, 95%CI, 0.54-2.08) had similar low risk of diabetes. Patients exposed to olanzapine had an increased risk of diabetes (aHR 1.71, 95%CI, 1.12-2.61), and although the effect estimate is imprecise, clozapine-exposed patients had a trend towards an elevated hazard ratio (aHR 2.58, 95%CI, 0.76-8.80). Results for the simple cohort were similar. CONCLUSIONS Relative to typical antipsychotics, aripiprazole, ziprasidone, risperidone and quetiapine were not associated with an increased risk of diabetes; olanzapine and clozapine were associated with an increased risk. This analysis constitutes the largest post-marketing pharmacoepidemiologic study to date that includes the newer agents.
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Abstract
Recently, increasing attention has been drawn to the potential diabetogenic effect of novel antipsychotics. Until now, large prospective studies examining the relationship between atypical antipsychotics and impaired glucose metabolism have been lacking. However, the case reports and retrospective studies that we review here suggest an increased risk of developing diabetes mellitus (DM) in patients treated with atypical antipsychotics compared to schizophrenic patients treated with conventional antipsychotics or those without treatment. Although most atypical antipsychotic agents might have a diabetogenic potential, the risk of developing DM might be higher in patients treated with either clozapine or olanzapine than with risperidone, whereas data on quetiapine and ziprasidone is presently limited and needs further attention. Possible mechanisms include the induction of peripheral insulin resistance and the direct influence on pancreatic beta-cell function by 5-HT1A/2A/2C receptor antagonism, by inhibitory effects via alpha 2-adrenergic receptors or by toxic effects. On the other hand, atypical antipsychotics might not be an independent risk factor for the development of DM, but hasten the onset of DM in patients bearing other risk factors. It is suggested that schizophrenic patients should be monitored for the occurrence of glucose metabolism abnormalities before starting atypical antipsychotics, and at a 3-month interval at least during therapy.
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Affiliation(s)
- Peter Schwenkreis
- Department of Psychiatry and Psychotherapty, Ruhr-University of Bochum, Germany
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Taylor DM, Douglas-Hall P, Olofinjana B, Whiskey E, Thomas A. Reasons for discontinuing clozapine: matched, case-control comparison with risperidone long-acting injection. Br J Psychiatry 2009; 194:165-7. [PMID: 19182180 DOI: 10.1192/bjp.bp.108.051979] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Clozapine has a range of serious adverse effects that may give rise to an increased risk of death. AIMS To compare reasons for discontinuation of clozapine with reasons for discontinuation of risperidone long-acting injection in age-matched individuals treated in the same clinical environment. METHOD Comparison of patients receiving clozapine and an age-matched control group receiving risperidone injection. RESULTS We established outcome for 529 consecutive patients receiving clozapine and 250 receiving risperidone (161 discontinuers from each group were compared). Adverse effects (odds ratio OR=2.19, 95% CI 1.31-3.67) and death (OR=7.0, 95% CI 2.09-23.5) were more commonly observed as reasons for discontinuation of clozapine than of risperidone. Clozapine was less likely to be withdrawn because of ineffectiveness than was risperidone (OR=0.034, 95% CI 0.01-0.14). Standardised mortality ratio (SMR) was significantly raised for patients receiving clozapine (SMR=4.17, 95% CI 2.78-6.26). Pneumonia was the most common single cause of death. CONCLUSIONS Clozapine use in patients with severe mental illness was associated with a significantly increased risk of death compared with that for the general population. Causation could not be established. Adverse effects and death are common causes of clozapine discontinuation.
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Affiliation(s)
- David M Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, UK.
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Clozapine causes oxidation of proteins involved in energy metabolism: a possible mechanism for antipsychotic-induced metabolic alterations. Int J Neuropsychopharmacol 2008; 11:1097-104. [PMID: 18466668 DOI: 10.1017/s1461145708008882] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Although atypical antipsychotics are widely known to induce alterations in lipid and glucose metabolism, the mechanisms by which these alterations occur remain unknown. Several recent studies have shown that atypical antipsychotics induce oxidative stress and oxidative cell injury by increasing levels of lipid and protein oxidation. In this study, a novel proteomic approach was used to identify specific proteins oxidized after clozapine treatment. Differentiated neuroblastoma SKNSH cells were treated with 0, 5 or 20 mum clozapine for 24 h and protein extracts were labelled with 6-iodoacetamide fluorescein (6-IAF). The lack of incorporation of 6-IAF to cysteine residues is an indicator of protein oxidation. Labelled proteins were exposed to 2D electrophoresis, and differential protein labelling was assessed. Increased oxidation after clozapine treatment was observed in 10 protein spots (p<0.05), although only four of them remained significant after correcting for analysis with two drug concentrations. Five proteins, corresponding to nine of the spots, were identified by HPLC-electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS) as mitochondrial ribosomal protein S22, mitochondrial malate dehydrogenase, calumenin, pyruvate kinase and 3-oxoacid CoA transferase. The latter four proteins play important roles in energy metabolism. These results suggest that oxidative stress may be a mechanism by which antipsychotics increase the risk for metabolic syndrome and diabetes.
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