Safety of clozapine use during pregnancy: Analysis of international pharmacovigilance data

Clozapine-Induced Severe Toxicity: Exploring the Pharmacokinetic Profile of Clozapine and Its Significance in Hemodynamic Instability - A Case Report

Hemodynamic instability in patients with clozapine intoxication can indirectly reflect the serum concentration of clozapine.We have described a case of a 32-year-old pregnant woman who developed life-threatening clozapine toxicity at 28 weeks of gestation. The levels of clozapine and norclozapine in the serum were high. We initiated hemoperfusion(HP) and other detoxification therapies to remove the drug. The patient had severely dilated peripheral blood vessels, which led to cardiac symptoms such as fatal hypotension and uncontrollable tachycardia, resulting in very high cardiac output and elevated Central venous oxygen saturation (ScvO2). Pharmacological intervention significantly improved the hemodynamics.In light of our observations in the ongoing case, we posit that evaluating hemodynamic parameters before and after blood detoxification could serve as a valuable means to gauge effectiveness and provide guidance for treatment.

Safety profile of monoclonal antibodies targeting the calcitonin gene-related peptide system in pregnancy: Updated analysis in VigiBase®

BACKGROUND

Safety data on the use of migraine preventive monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) system in pregnancy are limited.

METHODS

Updated pharmacovigilance assessment of the safety reports related to pregnancy associated with erenumab, galcanezumab, fremanezumab and eptinezumab, retrieved from VigiBase® as of 31 December 2021. As primary outcome, the whole group of monoclonal antibodies targeting the CGRP system was considered and sex and age subgroup disproportionality analyses using the reporting odds ratio (ROR) were conducted.

RESULTS

286 safety reports were found: 116 (40.6%) on erenumab, 125 (43.7%) on galcanezumab, 39 (13.6%) on fremanezumab, 6 (2.1%) on eptinezumab. One hundred and forty-nine (52.1%) safety reports reported only drug exposure in relation to pregnancy while 137 (47.9%) also included ≥1 pregnancy outcomes: maternal outcomes (n = 64), spontaneous abortion (n = 63), foetal growth restriction (n = 1), prematurity (n = 8), neonatal outcomes (n = 13), and poor breastfeeding (n = 1). No specific patterns of maternal, foetal and neonatal toxicity were observed. Spontaneous abortion was not disproportionally more frequently reported with erenumab, galcanezumab, fremanezumab and eptinezumab compared with the entire database (ROR 1.1, 95% confidence interval, CI, 0.8-1.5), the entire database since 2018 (ROR 1.3, 95% CI 1.0-1.8), and triptans (ROR 1.2, 95% CI 0.8-1.9).

CONCLUSIONS

This updated safety analysis on erenumab, galcanezumab, fremanezumab and eptinezumab in pregnancy showed no signals of foeto-maternal toxicity according to VigiBase® safety reports.

Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia

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.

Immune Checkpoint Inhibitors and Pregnancy: Analysis of the VigiBase® Spontaneous Reporting System

In pregnancy, immune checkpoint pathways are involved in the maintenance of fetomaternal immune tolerance. Preclinical studies have shown that immune checkpoint inhibitors (ICIs) increase the risk of fetal death. Despite the fact that using ICIs in pregnant women and women of childbearing potential is not recommended, some case reports of ICI exposure in pregnancy have been published showing favorable fetal outcomes. This study aimed to gain further insight into ICI safety in pregnancy by querying VigiBase^®, the World Health Organization's spontaneous reporting system. We performed raw and subgroup disproportionality analyses using the reporting odds ratio and comparing ICIs with the entire database, other antineoplastic agents, and other antineoplastic agents gathered in VigiBase^® since 2011. Across 103 safety reports referring to ICI exposure during the peri-pregnancy period, 56 reported pregnancy-related outcomes, of which 46 were without concomitant drugs as potential confounding factors. No signals of disproportionate reporting were found for spontaneous abortion, fetal growth restriction, and prematurity. In light of the expanding indications of ICIs, continuous surveillance by clinicians and pharmacovigilance experts is warranted, along with pharmacoepidemiological studies on other sources of real-world evidence, such as birth records, to precisely assess ICI exposure during the peri-pregnancy period and further characterize relevant outcomes.

Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations

INTRODUCTION

The perinatal period in schizophrenia is associated with high risk of psychotic relapse and pregnancy/child outcomes. The extent to which antipsychotics may potentially affect the fetus or the child development is unclear and debated. Even though guidelines have been developed, there is a lack of consensual recommendations regarding the optimal strategy to manage schizophrenia during the perinatal period.

AREAS COVERED

This systematic review describes the current state of evidence with respect to the impact of recommended interventions for schizophrenia during the perinatal period, including childbearing age, pregnancy and post-partum. It compares recent international treatment guidelines for this specific group of women. Last, this review presents a set of major points to be discussed with patients and relatives for shared-decision making and a summary of key recommendations from the international guidelines.

EXPERT OPINION

Although treatment guidelines may be of significant help, discrepancies exist across them regarding the management of antipsychotics for schizophrenia women during the perinatal period. Shared decision-making and advance directives represent useful patient-centered approaches during this specific period. Further cohort-based evidence is needed to better identify maternal and fetal risks associated to antipsychotic treatment exposure.

A systematic review of maternal and infant outcomes after clozapine continuation in pregnancy

OBJECTIVE

While there is a general lack of evidence of the safety of antipsychotic medications in pregnancy, there is a specific reluctance to continue clozapine in treatment resistant patients who become pregnant. Our aim is to systematically review adverse maternal and infant outcomes following clozapine use during pregnancy.

METHOD

A systematic review of all observational and intervention studies which highlighted adverse maternal and infant outcomes following clozapine continuation in pregnancy was undertaken. Article selection and quality were independently assessed and PRISMA guidelines adhered to.

RESULTS

Of 481 studies identified only two studies met the inclusion criteria. Both were rated as poor quality. The first found no significant increase in any adverse maternal or infant outcomes associated with antipsychotic exposure, except an increased rate of low birth weight in antipsychotic exposed babies. The number of patients exposed to clozapine was too small for separate statistical analysis. The second study found higher APGAR scoring at one minute for the clozapine group, but the scores were not statistically different at five-minutes.

CONCLUSION

Limited evidence was found to show significant adverse maternal and infant outcomes in pregnancy following clozapine continuation.Key messagesLimited evidence to show that clozapine has adverse effects on mother and infant when used during pregnancy.Risk/benefit analysis should be done thoroughly for each individual patient regarding clozapine continuation when pregnancy is confirmed.Close monitoring of mother and infant during perinatal period when clozapine is continued.Further research is needed to more clearly define the effects of clozapine on mother and infant during pregnancy and into the postnatal period.

Antipsychotic medication for women with schizophrenia spectrum disorders

There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.

Schizophrenia during pregnancy

PURPOSE OF REVIEW

A diagnosis of schizophrenia has significant implications for women of childbearing age, pregnant or considering a pregnancy, ranging from sexual health, psychopharmacological treatment, to the occurrence of negative pregnancy and foetal outcomes. We provide a short narrative review of recent papers focusing on these issues.

RECENT FINDINGS

Although pregnancy rates have been increasing in women with a diagnosis of schizophrenia, they also tend to have altogether fewer pregnancies and fewer live births than women without this diagnosis, and also higher rates of induced abortions.Use of antipsychotics in pregnancy has also increased, and evidence suggests lack of significant contraindications for their use in this period. However, drug levels monitoring may be recommended across the three trimesters, as levels may change in relation to pregnancy-related physiology.Monitoring of physical health is an increasingly crucial issue, given higher risk of gestational diabetes, negative obstetric and infant outcomes in these women.

SUMMARY

There is an urgent need to generate valid and reproducible research that could help implement appropriate treatment protocols and relapse-prevention approaches, and interventions based on strong pharmaceutical targets for the benefit of pregnant women with a diagnosis of schizophrenia, their families and their children.

Safety of antipsychotic drugs: A systematic review of disproportionality analysis studies

Antipsychotic drugs are commonly prescribed, mainly for the treatment of schizophrenia and other psychotic disorders. Disproportionality analysis of pharmacovigilance data from national and international databases have been recently utilized to investigate the side-effect profiles of antipsychotics and have provided unique insights of their safety. Among several national and international spontaneous reporting databases the databases of the World Health Organization (VigiBase), of the European Medicines Agency (EudraVigilance) and the US Food and Drug Administration (FAERS) incorporate millions of Individual Case Safety Reports. The aim of our study was to systematically review published disproportionality analyses on antipsychotic drugs, in order to summarize the current state of methodology and potential strengths of this analysis while highlighting safety signal generated for these pharmacological group. PubMed was searched using a search algorithm combining terms for antipsychotic drugs and disproportionality analysis. A total of 39 articles were found to be eligible corresponding to 38 original disproportionality studies. Different measures of disproportionality were used in each study: reporting odds ratio (ROR), proportional reporting ratio (PRR), empirical Bayes geometric mean (EBGM) and the information component (IC). Despite the inherent limitations of the pharmacovigilance databases disproportionality analysis provides complemented evidence from RCTs on the safety of antipsychotics, especially regarding participants often excluded from RCTs, such as pregnant and breastfeeding women, children and participants with drug abuse, comorbidities or concomitant medications.

Maternal paracetamol intake and fetal ductus arteriosus constriction/closure: comprehensive signal evaluation using the Austin Bradford Hill criteria

PURPOSE

Acetaminophen (APAP) is available over-the-counter and widely regarded as safe for use in pregnancy. APAP has been used to close a persistently patent ductus arteriosus. Fetal constriction/closure of the ductus arteriosus (FCCDA), of public health interest given the drug's widespread use during pregnancy, is being monitored globally, including by the European Medicines Agency Pharmacovigilance Risk Assessment Committee. Our objective was to share a comprehensive signal evaluation of FCCDA with in utero APAP exposure to determine if the totality of evidence is sufficiently more consistent with one of the following two possibilities: (1) APAP never contributes to FCCDA (null hypothesis or H_O) versus (2) APAP may in some cases be at least a contributory cause of in utero DA narrowing (alternative hypothesis or H_A) to justify risk communication.

METHODS

To assess the relative support for H_O versus H_A, we synthesize and interpret within an Austin Bradford Hill criteria framework a comprehensive, cross-disciplinary set of published information and de novo analysis, including toxicology, epidemiology, clinical pharmacology, and clinical and quantitative pharmacovigilance analysis of spontaneous reports.

RESULTS

While residual uncertainty remains, the totality of information is more compatible with H_A than H₀, to the extent that it is reasonably possible that APAP may sometimes be at least a contributory cause of FCCDA.

CONCLUSION

It is reasonably possible that APAP may sometimes be at least a contributory cause of FCCDA, and this should therefore be communicated to stakeholders.

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CLINICALTRIALS.

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