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Jeong SH, Lee MG, Kim YS, Chung IW. Change in absolute neutrophil count after COVID-19 infection in patients using clozapine versus other antipsychotics. Int Clin Psychopharmacol 2024; 39:187-194. [PMID: 38261424 DOI: 10.1097/yic.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
It was reported that patients who contracted COVID-19 while taking clozapine exhibited a distinct hematological response. However, the absence of control groups made it difficult to attribute it to clozapine. The changes in absolute neutrophil counts (ANCs) during the 4 weeks after COVID-19 infection were compared between the two groups of patients with severe mental illnesses (SMIs) (49 patients using clozapine and 54 using other antipsychotics) using generalized additive modeling. Although the pattern of a transient drop in ANC followed by gradual recovery could be demonstrated in both groups, it was more pronounced in the clozapine group ( P = 0.00025). Nevertheless, overall ANC remained at a higher level in the clozapine group. The results suggested potential interaction between clozapine and COVID-19 at the level of hematological dynamics. However, it did not necessarily indicate that such interaction is inevitably harmful or dangerous. It was more of a concern that some patients using other antipsychotics exhibited decreased ANC, which did not easily recover. Traditionally, clinicians have been concerned about the worsening of hematological side effects in clozapine patients after COVID-19 infection. However, the obtained result highlighted the necessity of hematological monitoring in patients using any type of antipsychotics for SMIs.
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Affiliation(s)
- Seong Hoon Jeong
- Department of Psychiatry, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon
| | | | - Yong Sik Kim
- Department of Psychiatry, Nowon-Uiijeongbu Eulji Medical Center, Eulji University School of Medicine, Seoul
- Institute of Clinical Psychopharmacology, Dongguk University School of Medicine, Goyang
| | - In Won Chung
- Department of Psychiatry and Yong-In Psychiatric Institute, Yong-In Mental Hospital, Yongin, Republic of Korea
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Oloyede E, Dzahini O, Abolou Z, Gee S, Whiskey E, Malhotra D, Hussain M, Osborne I, Casetta C, McGuire P, MacCabe JH, Taylor D. Clinical impact of reducing the frequency of clozapine monitoring: controlled mirror-image cohort study. Br J Psychiatry 2023:1-7. [PMID: 37092691 PMCID: PMC10391318 DOI: 10.1192/bjp.2023.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND To minimise infection during COVID-19, the clozapine haematological monitoring interval was extended from 4-weekly to 12-weekly intervals in South London and Maudsley NHS Foundation Trust. AIMS To investigate the impact of this temporary policy change on clinical and safety outcomes. METHOD All patients who received clozapine treatment with extended (12-weekly) monitoring in a large London National Health Service trust were included in a 1-year mirror-image study. A comparison group was selected with standard monitoring. The proportion of participants with mild to severe neutropenia and the proportion of participants attending the emergency department for clozapine-induced severe neutropenia treatment during the follow-up period were compared. Psychiatric hospital admission rates, clozapine dose and concomitant psychotropic medication in the 1 year before and the 1 year after extended monitoring were compared. All-cause clozapine discontinuation at 1-year follow-up was examined. RESULTS Of 569 participants, 459 received clozapine with extended monitoring and 110 controls continued as normal. The total person-years were 458 in the intervention group and 109 in the control group, with a median follow-up time of 1 year in both groups. During follow-up, two participants (0.4%) recorded mild to moderate neutropenia in the intervention group and one (0.9%) in the control group. There was no difference in the incidence of haematological events between the two groups (IRR = 0.48, 95% CI 0.02-28.15, P = 0.29). All neutropenia cases in the intervention group were mild, co-occurring during COVID-19 infection. The median number of admissions per patient during the pre-mirror period remained unchanged (0, IQR = 0) during the post-mirror period. There was one death in the control group, secondary to COVID-19 infection. CONCLUSIONS There was no evidence that the incidence of severe neutropenia was increased in those receiving extended monitoring.
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Affiliation(s)
- Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK; and Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Olubanke Dzahini
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Zadro Abolou
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | | | - Masuma Hussain
- South West London and St George's Mental Health NHS Trust, London, UK
| | - Ian Osborne
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - James H MacCabe
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
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Giles G, Varghese S, Shymko G, Nguyen T, Waters F. Clozapine Therapy and COVID-19: A Systematic Review of the Prevalence Rates, Health Outcomes, Hematological Markers, and Patient Perspectives. Schizophr Bull 2022; 49:53-67. [PMID: 36242537 PMCID: PMC9620749 DOI: 10.1093/schbul/sbac148] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND/OBJECTIVES There have been concerns that clozapine treatment may undermine the capacity of the body to fight infection and increase the vulnerability to contracting COVID-19. This review of recent cohort studies investigated (1) whether people with a severe psychiatric disorder are at increased risk of COVID-19 and complications, (2) the immunological response of clozapine-users who contract COVID-19, and (3) patients' perspectives on COVID-19 and the pandemic response. METHODS A systematic search of EMBASE, Medline, Pubmed, and PsycINFO databases using PRISMA guidelines using "COVID-19", "clozapine", and "vaccination" terms. RESULTS 18 studies (out of 330 identified) met all criteria (N = 119 054 including 8045 on clozapine). There was no strong evidence that clozapine users may be at increased risk of contracting COVID-19 or developing complications after adjusting for medical comorbidities. Hematological studies showed temporary reductions in neutrophils in COVID-19-positive patients and vaccination suggesting a clozapine effect in defence against infection. Vaccination studies did not report major adverse effects. Increased plasma levels of clozapine and neutropenia however point to COVID-19-related interference of clozapine metabolism. Patient surveys reported limited impact on mental health and positive attitudes regarding pandemic response. CONCLUSION This review did not find compelling evidence that the immune system of clozapine users put them at risk of COVID-19 and further complications. Evidence of drug-infection interactions however points to the importance of adhering to consensus guidelines about clozapine therapy during the pandemic. More evidence using longitudinal designs is required to examine the longer-term effects of COVID-19 and vaccination in this vulnerable population.
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Affiliation(s)
- Grace Giles
- To whom correspondence should be addressed; Peel and Rockingham Kwinana Mental Health Service, Elanora Drive, Cooloongup, Western Australia, 6168, Australia; tel: 08 95994933, fax: 08 95994966, e-mail:
| | - Sunny Varghese
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Gordon Shymko
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia
| | - Thinh Nguyen
- South Metropolitan Health Service, Peel and Rockingham Kwinana (PaRK) Mental Health Service, Rockingham, Western Australia, 6168, Australia,Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia
| | - Flavie Waters
- Division of Psychiatry, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia,School of Psychological Sciences, The University of Western Australia, 35 Stirling Highway, Perth, Western Australia, 6009, Australia,Clinical Research Centre, Graylands Hospital Campus, North Metropolitan Area Services-Mental Health, Brockway Road, Mount Claremont, Perth, Western Australia, 6010, Australia
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Grover S, Naskar C, Sahoo S, Mehra A, Chakrabarti S. Starting clozapine in patients with schizophrenia during the ongoing pandemic. Schizophr Res 2022; 243:440-442. [PMID: 34303594 PMCID: PMC8295063 DOI: 10.1016/j.schres.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Chandrima Naskar
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Swapnajeet Sahoo
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aseem Mehra
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Subho Chakrabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Taylor D, Vallianatou K, Whiskey E, Dzahini O, MacCabe J. Distinctive pattern of neutrophil count change in clozapine-associated, life-threatening agranulocytosis. NPJ Schizophr 2022; 8:21. [PMID: 35288577 DOI: 10.1038/s41537-022-00232-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/11/2022] [Indexed: 12/19/2022]
Abstract
The wider use of clozapine is limited by the risk of agranulocytosis and the associated requirement for monitoring of neutrophil counts. We searched local electronic patient records for cases of agranulocytosis occurring during clozapine treatment during the period 2007–2020. We found 23 episodes recorded as agranulocytosis in clozapine patients. Of these, nine met pre-defined criteria and were considered episodes of life-threatening agranulocytosis (LTA). These episodes of clozapine-induced LTA exhibited a distinct pattern of continuous and rapid neutrophil count decline to zero or near zero. Mean time for neutrophils to fall from ANC > 2 to ANC <0.5 × 109/L was 8.4 days (range 2–15 days). Each event was also characterised by a prolonged nadir and delayed recovery (range 4–16 days). Non-LTA episodes were, in contrast, brief and benign. We conclude that an important proportion of cases of agranulocytosis identified in people prescribed clozapine are not life-threatening and may not even be clozapine-related. Monitoring schemes should aim to identify true clozapine-induced LTA as opposed to threshold-defined nominal agranulocytosis. Genetics studies might benefit from examining associations with clozapine-induced LTA rather than with recorded cases of agranulocytosis or neutropenia.
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Grover S, Kathiravan S, Naskar C, Suman A, Sahoo S, Mehra A, Chakrabarti S. Can lowering of haematological monitoring for clozapine be considered in the future? Asian J Psychiatr 2021; 64:102796. [PMID: 34333342 DOI: 10.1016/j.ajp.2021.102796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandrima Naskar
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aarzoo Suman
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Swapnajeet Sahoo
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aseem Mehra
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Aubignat M. Clozapine-related immunodeficiency: Implications for Parkinson's disease psychosis in the context of the COVID-19 pandemic. Rev Neurol (Paris) 2021:S0035-3787(21)00584-1. [PMID: 34217512 DOI: 10.1016/j.neurol.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 12/29/2022]
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