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de Leon J, Wang L, Simpson GM. The introduction of clozapine at the Nathan Kline Institute in New York and its long-term consequences. Schizophr Res 2024; 268:14-20. [PMID: 37689508 DOI: 10.1016/j.schres.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
Nathan S. Kline was a pioneer in psychopharmacology in the United States (US). In 1952, Kline started a research unit at Rockland State Hospital, New York. Kline brought clozapine from Switzerland since it was not yet available in the US. At Rockland State Hospital, George Simpson had conducted antipsychotic trials and had developed scales to assess movement disorders. In 1974, Simpson published the first US clozapine trial. In 1978, he published on 1) the effect of clozapine on tardive dyskinesia and 2) high plasma clozapine concentrations in two patients with seizures. His experience of clozapine withdrawal symptoms in his first 2 trials led in the future to more articles in this area. In Philadelphia, Simpson designed a double-blind randomized clinical trial (RCT) with 3 doses (100, 300 and 600 mg/day) which was published in 1999. From the 50 patients started on the RCT, 47 provided repeated plasma clozapine concentrations every other week of the RCT. This rich database of plasma clozapine concentrations under controlled conditions has contributed to many of the advances in clozapine pharmacokinetics in the last 5 years including: 1) obesity can be associated with clozapine poor metabolism (PM) status, 2) a clozapine ultrarapid metabolizer (UM) with a minimum therapeutic dose of 1591 mg/day, 3) a case of clozapine intoxication dropped from the RCT due to pneumonia, 4) cases of increased plasma concentrations during clozapine-induced fever, 5) the possibility that African-Americans may need higher clozapine doses than those of European ancestry, and 6) three indices of non-adherence.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain.
| | - Linda Wang
- Department of Psychiatry, University of Southern California, Los Angeles, CA, United States of America
| | - George M Simpson
- Department of Psychiatry, University of Southern California, Los Angeles, CA, United States of America.
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Li K, Zhou P, Li J, Cheng Y, Li S, Wang Y, Jiang W, Bai Y, Cao H, Wang D. Upregulation of P2Y14 receptor in neutrophils promotes inflammation after myocardial ischemia/reperfusion injury. Life Sci 2023:121805. [PMID: 37236604 DOI: 10.1016/j.lfs.2023.121805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/13/2023] [Accepted: 05/22/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND P2Y14 receptor is expressed in neutrophils and is involved in activation of inflammatory signaling. However, the expression and function of P2Y14 receptor in neutrophils after myocardial infarction/reperfusion (MIR) injury remain to be elucidated. METHODS In this research, rodent and cellular models of MIR were used to detect the involvement and function of P2Y14 receptor, as well as the regulation of inflammatory signaling via P2Y14 receptor in neutrophils post-MIR. RESULTS In the early stage post MIR, the expression of P2Y14 receptor was upregulated in CD4+Ly-6G+ neutrophils. Additionally, the expression of P2Y14 receptor was highly induced in neutrophils subjected to uridine 5'-diphosphoglucose (UDP-Glu), which is proven to be secreted by cardiomyocytes during ischemia and reperfusion. Our results also showed the beneficial role of P2Y14 receptor antagonist PPTN in counteracting inflammation via promoting polarization of neutrophils to N2 phenotype in the infarct area of the heart tissue after MIR. CONCLUSION These findings prove that the P2Y14 receptor is involved in the regulation of inflammation in the infarct area after MIR, and establish a novel signaling pathway concerning the interplay between cardiomyocytes and neutrophils in the heart tissue.
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Affiliation(s)
- Kunsheng Li
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, GuangZhou 515000, Guangdong Province, PR China
| | - Jie Li
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China
| | - Yongqing Cheng
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China
| | - Shiliang Li
- Department of Cardiac Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, PR China
| | - Yumeng Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China
| | - Weipeng Jiang
- Department of Cardiology, South China Hospital of Shenzhen University, Longgang District, Shenzhen 518111, PR China
| | - Yang Bai
- Department of Cardiac Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, PR China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, PR China.
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Horowitz MA, Moncrieff J, de Haan L, Bogers JPAM, Gangadin SS, Kikkert M, Veling W, Sommer IEC. Tapering antipsychotic medication: practical considerations. Psychol Med 2022; 52:32-35. [PMID: 34542027 DOI: 10.1017/s0033291721003299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Mark A Horowitz
- Department of Psychiatry, University College London, London, UK
- Goodmayes Hospital, North East London NHS Foundation Trust, London, UK
| | - Joanna Moncrieff
- Department of Psychiatry, University College London, London, UK
- Goodmayes Hospital, North East London NHS Foundation Trust, London, UK
| | - Lieuwe de Haan
- Amsterdam UMC, location AMC/Arkin, Amsterdam, Netherlands
| | - Jan P A M Bogers
- Mental Health Organisation Rivierduinen, High Care Clinics, Leiden, The Netherlands
| | - Shiral S Gangadin
- Department of Biomedical Sciences of Cells and Systems, Rijksuniversiteit Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Wim Veling
- Department of Psychiatry, Rijksuniversiteit Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Iris E C Sommer
- Department of Biomedical Sciences of Cells and Systems, Rijksuniversiteit Groningen, University Medical Center Groningen, Groningen, Netherlands
- Department of Psychiatry, Rijksuniversiteit Groningen, University Medical Center Groningen, Groningen, Netherlands
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Harshe D, Nagda P, Gore S. Delirium after abrupt discontinuation of clozapnie. Asian J Psychiatr 2020; 53:102235. [PMID: 32590141 DOI: 10.1016/j.ajp.2020.102235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/13/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Devavrat Harshe
- Department of Psychiatry, D Y Patil Medical College, Kolhapur, 416006, India.
| | - Parth Nagda
- Department of Psychiatry, D Y Patil Medical College, Kolhapur, India
| | - Sneha Gore
- Department of Psychiatry, Rajarshee Chhatrapati Shahu Maharaj Government Medical College, Kolhapur, 416003, India
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De las Cuevas C, de Leon J. Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics. Patient Prefer Adherence 2020; 14:1823-1842. [PMID: 33116427 PMCID: PMC7555336 DOI: 10.2147/ppa.s242693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/25/2020] [Indexed: 12/18/2022] Open
Abstract
THE PROBLEM Poor adherence to appropriately prescribed medication is a global challenge for psychiatrists. PRIOR STUDIES Measuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients' self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it. EXPERT OPINION ON FUTURE STUDIES Future studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with non-adherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.
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Affiliation(s)
- Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
- Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
- Correspondence: Carlos De las CuevasDepartment of Internal Medicine, Dermatology and Psychiatry, Universidad de La Laguna,, Campus de Ofra s/n, San Cristóbal de La Laguna, Canary Islands, SpainTel +34-922-316502Fax +34-922-319353 Email
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Green A, Stephenson T, Whiskey E, Shergill SS. Closure beyond clozapine: successfully averting rebound symptoms in a patient with schizoaffective disorder and agranulocytosis. BJPsych Open 2019; 5:e43. [PMID: 31530315 PMCID: PMC6537554 DOI: 10.1192/bjo.2019.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
SUMMARY 'Rebound' or 'withdrawal' symptoms are frequently observed after a sudden discontinuation of clozapine. We describe a patient with treatment-resistant schizoaffective disorder who developed agranulocytosis on clozapine but was successfully switched to treatment with olanzapine with no deterioration in her condition. We put forward three possible theories which may have accounted for the lack of rebound symptoms in this patient: the pharmacological profile of olanzapine, the anticholinergic effects of hyoscine hydrobromide, and the possibility that this patient may not be treatment-resistant and so have a reduced risk of rebound psychosis due to displaying a different pathophysiology. DECLARATION OF INTEREST None.
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Affiliation(s)
- Alastair Green
- Medical Student, Medical School, St George's, University of London, UK
| | - Thomas Stephenson
- Core Psychiatry Trainee, Child and Adolescent Clinical Academic Group, South London and Maudsley NHS Foundation Trust, UK
| | - Eromona Whiskey
- Clinical Pharmacist, National Psychosis Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, UK
| | - Sukhi S Shergill
- Professor of Psychiatry & Systems Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London; and Honorary Consultant Psychiatrist, National Psychosis Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, UK
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Galova A, Berney P, Desmeules J, Sergentanis I, Besson M. A case report of cholinergic rebound syndrome following abrupt low-dose clozapine discontinuation in a patient with type I bipolar affective disorder. BMC Psychiatry 2019; 19:73. [PMID: 30782143 PMCID: PMC6381751 DOI: 10.1186/s12888-019-2055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/11/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rebound cholinergic syndrome is a rare, but well known unwanted phenomenon occurring after abrupt clozapine discontinuation. There have been previous reported cases of cholinergic rebound in the literature; however, these reports described cholinergic rebound following cessation of high doses of clozapine in patients diagnosed with schizophrenia. Here, we report a case of rebound cholinergic syndrome and catatonia in a male patient three days after abrupt discontinuation of 50 mg of clozapine prescribed for type I bipolar affective disorder. CASE PRESENTATION A 66-year old male of Spanish origin, treated for type I bipolar affective disorder for 15 years and for Crohn disease, was brought to the emergency department because of a sudden onset of mutism, dysphagia and trismus. He was described catatonic and presented hypertension, tachycardia and tachypnea. His body temperature was normal and the laboratory tests were unremarkable at presentation. A head CT and an EEG were in the normal range. While reviewing his history, it appeared the he was on clozapine 50 mg a day, first introduced 2 months ago, during a previous hospitalization for a manic episode resistant to other mood stabilizers. For an unknown reason, the patient's psychiatrist stopped clozapine three days before the admission and replaced it by risperidone 5 mg and quetiapine 200 mg daily. A cholinergic rebound syndrome was then evoked. The patient's ability to speak recovered dramatically and fast after the intravenous administration of 2.5 mg of biperiden supporting the diagnosis. Risperidone and quetiapine were also stopped. The patient fully recovered in 20 days after the reintroduction of 50 mg of clozapine and 2.5 mg of biperiden daily. CONCLUSIONS This case report underscores that cholinergic rebound syndrome may occur in patients suffering from bipolar affective disorders, being on clozapine as a mood stabilizer. The low dose clozapine does not preclude severe manifestations of the phenomenon. Progressive tapering should therefore be adopted in any case.
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Affiliation(s)
- Andrea Galova
- 0000 0001 0721 9812grid.150338.cPsychopharmacology Unit, Clinical pharmacology and toxicology division, Acute Medicine Department, Geneva University Hospital, Geneva, Switzerland
| | - Patricia Berney
- 0000 0001 0721 9812grid.150338.cPsychopharmacology Unit, Clinical pharmacology and toxicology division, Acute Medicine Department, Geneva University Hospital, Geneva, Switzerland
| | - Jules Desmeules
- 0000 0001 0721 9812grid.150338.cClinical pharmacology and toxicology division, Acute Medicice Department, Geneva University Hospital, Geneva, Switzerland
| | - Ioannis Sergentanis
- 0000 0001 0721 9812grid.150338.cLiaison Psychiatry and Crisis Intervention Unit, Psychiatry department, Geneva University Hospital, Geneva, Switzerland
| | - Marie Besson
- Psychopharmacology Unit, Clinical pharmacology and toxicology division, Acute Medicine Department, Geneva University Hospital, Geneva, Switzerland.
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Lander M, Bastiampillai T, Sareen J. Review of withdrawal catatonia: what does this reveal about clozapine? Transl Psychiatry 2018; 8:139. [PMID: 30065280 PMCID: PMC6068101 DOI: 10.1038/s41398-018-0192-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/05/2018] [Accepted: 05/11/2018] [Indexed: 12/23/2022] Open
Abstract
Withdrawal symptoms are common upon discontinuation of psychiatric medications. Catatonia, a neuropsychiatric condition proposed to be associated with gamma-aminobutyric acid (GABA) hypoactivity due to its robust response to benzodiazepines, has been described as a withdrawal syndrome in case reports but is not a well-recognized phenomenon. The authors undertook a review of withdrawal catatonia with an aim to understand its presentation as well as the medications and psychoactive substances it is associated with. The review identified 55 cases of withdrawal catatonia, the majority of which occurred upon discontinuation of benzodiazepines (24 cases) and discontinuation of clozapine (20 cases). No other antipsychotic medications were identified as having been associated with the onset of a catatonic episode within 2 weeks following their discontinuation. Increasing GABA activity and resultant GABA receptor adaptations with prolonged use is postulated as a shared pharmacological mechanism between clozapine and benzodiazepines that underlie their association with withdrawal catatonia. The existing evidence for clozapine's activity on the GABA system is reviewed. The clinical presentations of benzodiazepine withdrawal catatonia and clozapine withdrawal catatonia appear to differ and reasons for this are explored. One reason is that benzodiazepines act directly on GABAA receptors as allosteric agonists, while clozapine has more complex and indirect interactions, primarily through effects on receptors located on GABA interneurons. Another possible reason for the difference in clinical presentation is that clozapine withdrawal catatonia may also involve receptor adaptations in non-GABA receptors such as dopamine and acetylcholine. The findings from our review have implications for the treatment of withdrawal catatonia, and treatment recommendations are provided. Further research understanding the uniqueness of clozapine withdrawal catatonia among antipsychotic medication may give some insight as to clozapine's differential mechanism of action.
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Affiliation(s)
- Matthew Lander
- Department of Psychiatry, University of Manitoba, Winnipeg, Canada.
| | - Tarun Bastiampillai
- Discipline of Psychiatry, School of Medicine, Flinders University, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jitender Sareen
- Departments of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Canada
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Catatonia Secondary to Sudden Clozapine Withdrawal: A Case with Three Repeated Episodes and a Literature Review. Case Rep Psychiatry 2017; 2017:2402731. [PMID: 28396815 PMCID: PMC5370482 DOI: 10.1155/2017/2402731] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 02/26/2017] [Indexed: 02/06/2023] Open
Abstract
A literature search identified 9 previously published cases that were considered as possible cases of catatonia secondary to sudden clozapine withdrawal. Two of these 9 cases did not provide enough information to make a diagnosis of catatonia according to the Diagnostic and Statistical Manual, 5th Edition (DSM-5). The Liverpool Adverse Drug Reaction (ADR) Causality Scale was modified to assess ADRs secondary to drug withdrawal. From the 7 published cases which met DSM-5 catatonia criteria, using the modified scale, we established that 3 were definitive and 4 were probable cases of catatonia secondary to clozapine withdrawal. A new definitive case is described with three catatonic episodes which (1) occurred after sudden discontinuation of clozapine in the context of decades of follow-up, (2) had ≥3 of 12 DSM-5 catatonic symptoms and serum creatinine kinase elevation, and (3) required medical hospitalization and intravenous fluids. Clozapine may be a gamma-aminobutyric acid (GABA) receptor agonist; sudden clozapine withdrawal may explain a sudden decrease in GABA activity that may contribute to the development of catatonic symptoms in vulnerable patients. Based on the limited information from these cases, the pharmacological treatment for catatonia secondary to sudden clozapine withdrawal can include benzodiazepines and/or restarting clozapine.
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Sheehan R, Hassiotis A. Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: a systematic review. Lancet Psychiatry 2017; 4:238-256. [PMID: 27838214 DOI: 10.1016/s2215-0366(16)30191-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 01/20/2023]
Abstract
The use of antipsychotics to manage challenging behaviour in adults with intellectual disability is widespread but controversial, and evidence is scarce. There is a perception that antipsychotics used in this context can be reduced or discontinued, and this has been a major focus of recent national policy. However, such an intervention risks harm as well as having potential benefits. We reviewed the available evidence and found that antipsychotics can be reduced or discontinued in a substantial proportion of adults who use them for challenging behaviour, although not always without adverse effects. There is a group which displays behavioural deterioration on antipsychotic reduction that prevents discontinuation; predictors of poor response could not be reliably identified. In view of the relatively scarce data and methodological limitations of the available studies, we cannot draw firm conclusions to inform a population level approach to this issue. Antipsychotic medication used for behaviour should be reviewed regularly and an individualised approach taken to treatment.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, UK.
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Cheng M, Gu H, Zheng L, Wang H, Zhong Z, Wen S. Neuroleptic malignant syndrome and subsequent clozapine-withdrawal effects in a patient with refractory schizophrenia. Neuropsychiatr Dis Treat 2016; 12:695-7. [PMID: 27099499 PMCID: PMC4820214 DOI: 10.2147/ndt.s103687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Here, we report a female patient developing neuroleptic malignant syndrome following the use of a combination of clozapine and haloperidol. Subsequently, the patient presented withdrawal effects after an abrupt discontinuation of clozapine. Psychiatrists not aware of possible clozapine-withdrawal effects may misdiagnose as a part of the primary mental illness or as the initial symptoms worsening, if unrecognized.
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Affiliation(s)
- Minfeng Cheng
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Huaying Gu
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Liangrong Zheng
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Houliang Wang
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhiyong Zhong
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Shenglin Wen
- Department of Psychiatry, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
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12
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O'Connor WT, O'Shea SD. Clozapine and GABA transmission in schizophrenia disease models. Pharmacol Ther 2015; 150:47-80. [DOI: 10.1016/j.pharmthera.2015.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
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Brissos S, Veguilla MR, Taylor D, Balanzá-Martinez V. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal. Ther Adv Psychopharmacol 2014; 4:198-219. [PMID: 25360245 PMCID: PMC4212490 DOI: 10.1177/2045125314540297] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.
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Affiliation(s)
- Sofia Brissos
- Psychiatrist, Lisbon's Psychiatric Hospitalar Centre, Rua Conde de Redondo, nº 8 3º dt., Lisbon, 1150, Portugal
| | - Miguel Ruiz Veguilla
- Grupo Psicosis y Neurodesarrollo, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocio /CSIC/Universidad de Sevilla, Unidad de Hospitalizacion de Salud Mental, Sevilla, Spain
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, Pharmacy Department, Maudsley Hospital, Denmark Hill, London, UK
| | - Vicent Balanzá-Martinez
- Catarroja Mental Health Unit, University Hospital Doctor Peset, FISABIO, Valencia; and Section of Psychiatry, University of Valencia, CIBERSAM, Valencia, Spain
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Salomon C, Hamilton B. Antipsychotic discontinuation syndromes: a narrative review of the evidence and its integration into Australian mental health nursing textbooks. Int J Ment Health Nurs 2014; 23:69-78. [PMID: 23211033 DOI: 10.1111/j.1447-0349.2012.00889.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In light of the high number of people discontinuing antipsychotics each year, it is essential that nurses develop a robust understanding of all aspects of the discontinuation experience. While there is a large body of published work documenting post-discontinuation relapse rates, less is known about other aspects of the discontinuation experience. This paper presents the results of a narrative review of international studies of antipsychotic discontinuation syndromes and their relevance to nursing practice. Four key mental health nursing textbooks used in student nurse education in Australia are examined to assess how this evidence has been incorporated into clinical recommendations. This review finds that the evidence for discontinuation syndromes could be more widely disseminated and applied than it is at present. Strikingly, this evidence has not been incorporated into key mental health nursing textbooks in Australia at all. Slow integration into nursing published work may be influenced by a number of clinical and research uncertainties. We consider the impact of this silence on key nursing roles of psycho-education and adverse event monitoring during antipsychotic discontinuation periods. Further robust research should be conducted into discontinuation syndromes as a matter of urgency. Given the high number of consumers potentially impacted upon by discontinuation syndromes, nurse authors and educators should consider revising key nursing textbooks to include the currently available information about discontinuation syndromes.
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Affiliation(s)
- Carmela Salomon
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Solhaug H, Germans S, Romuld E, Kristiansen O. En mann i 50-årene med feber, redusert bevissthet og rigiditet. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:49-52. [DOI: 10.4045/tidsskr.10.0645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Miller R. Mechanisms of action of antipsychotic drugs of different classes, refractoriness to therapeutic effects of classical neuroleptics, and individual variation in sensitivity to their actions: Part II. Curr Neuropharmacol 2011; 7:315-30. [PMID: 20514211 PMCID: PMC2811865 DOI: 10.2174/157015909790031184] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 07/15/2009] [Accepted: 07/28/2009] [Indexed: 11/22/2022] Open
Abstract
Rapid-onset psychotic rebound is uncommon on discontinuation of most antipsychotic drugs, as might be expected for antipsychotic drugs with (hypothetically) indirect actions at their final target receptors. Rapid-onset psychosis is more common on withdrawal of clozapine, which might be expected if its action is direct. Drugs other than clozapine (notably thioridazine) may have hitherto unrecognised similarities to clozapine (but without danger of agranulocytosis), and may be useful in treatment of refractory psychosis. Quetiapine fulfils only some criteria for a clozapine-like drug. Clinical response to neuroleptics varies widely at any given plasma level. Haase's "neuroleptic threshold" concept suggests that the dose producing the slightest motor side effects produces most or all of the therapeutic benefit, but analyses presented here suggest that antipsychotic actions are not subject to a sharp "all-or-none" threshold but increase over a small dose range. This concept could provide a method for quantitative determination of individualized optimal doses.
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Affiliation(s)
- R Miller
- Otago Centre for Theoretical Studies in Psychiatry and Neuroscience (OCTSPAN), Department of Anatomy and Structural Biology, School of Medical Sciences, University of Otago, P.O.Box 913, Dunedin, New Zealand.
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MacKenzie EM, Odontiadis J, Le Mellédo JM, Prior TI, Baker GBI. The relevance of neuroactive steroids in schizophrenia, depression, and anxiety disorders. Cell Mol Neurobiol 2008; 27:541-74. [PMID: 17235696 DOI: 10.1007/s10571-006-9086-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 05/05/2006] [Indexed: 12/19/2022]
Abstract
1. Neuroactive steroids are steroid hormones that exert rapid, nongenomic effects at ligand-gated ion channels. There is increasing awareness of the possible role of these steroids in the pathology and manifestation of symptoms of psychiatric disorders. The aim of this paper is to review the current knowledge of neuroactive steroid functioning in the central nervous system, and to assess the role of neuroactive steroids in the pathophysiology and treatment of symptoms of schizophrenia, depression, and anxiety disorders. Particular emphasis will be placed on GABAA receptor modulation, given the extensive knowledge of the interactions between this receptor complex, neuroactive steroids, and psychiatric illness. 2. A brief description of neuroactive steroid metabolism is followed by a discussion of the interactions of neuroactive steroids with acute and chronic stress and the HPA axis. Preclinical and clinical studies related to psychiatric disorders that have been conducted on neuroactive steroids are also described. 3. Plasma concentrations of some neuroactive steroids are altered in individuals suffering from schizophrenia, depression, or anxiety disorders compared to values in healthy controls. Some drugs used to treat these disorders have been reported to alter plasma and brain concentrations in clinical and preclinical studies, respectively. 4. Further research is warranted into the role of neuroactive steroids in the pathophysiology of psychiatric illnesses and the possible role of these steroids in the successful treatment of these disorders.
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Affiliation(s)
- Erin M MacKenzie
- Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Canada
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Moncrieff J. Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset psychosis (supersensitivity psychosis) and withdrawal-related relapse. Acta Psychiatr Scand 2006; 114:3-13. [PMID: 16774655 DOI: 10.1111/j.1600-0447.2006.00787.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the evidence that discontinuation of long-term antipsychotic medication, including clozapine, may provoke a psychotic episode. METHOD Databases were searched and citations scrutinised. RESULTS Evidence for a rapid onset psychosis (supersensitivity psychosis) following clozapine withdrawal was found and weaker evidence that this might occur with some other antipsychotic drugs. Some cases were reported in people without a psychiatric history. It appears that the psychosis may be a feature of drug withdrawal rather than the re-emergence of an underlying illness, at least in some patients. Meta-analyses of withdrawal studies have suggested that antipsychotic discontinuation may also increase the risk of relapse over and above the risk because of the underlying disorder, but not all individual studies show this effect. Mechanisms may relate to brain adaptations to long-term drug use but data are sparse. CONCLUSION These effects require further urgent research. Interventions to reduce morbidity after drug withdrawal need to be developed.
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Affiliation(s)
- J Moncrieff
- Department of Mental Health Science, University College London, London, UK.
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Abstract
Atypical antipsychotics offer broader efficacy and improved tolerability compared with conventional agents. Many patients currently treated with conventional antipsychotics continue to experience persistent symptoms or troublesome side effects and may benefit from a change to one of the newer atypical agents. There are also significant differences in the side-effect profiles of the atypicals, such that a switch from one atypical agent to another could offer advantages to many patients. Unfortunately, many clinicians remain uncertain about the switching process and are reluctant to initiate change. The aim of this review is to identify the indications for a switch in antipsychotic therapy with a focus on recent switching data for the atypical antipsychotic, quetiapine. The clinical aspects of quetiapine's receptor binding characteristics are reviewed including the implications of the low D(2) antagonist properties that make quetiapine the treatment of choice when EPS persists with other atypical antipsychotics. Practical guidelines are given for managing the process of changeover, for avoiding pitfalls and for maximizing the chances of a successful switch. For example, when managing the antipsychotic crossover, it is important to consider the psychological effects of switching arising from symptom and side-effect changes. Finally, advice is provided on the assessments necessary when evaluating the success of a change in therapy, together with guidance on the optimal duration of treatment trials.
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Affiliation(s)
- Peter J Weiden
- Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.
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Edlinger M, Baumgartner S, Eltanaihi-Furtmüller N, Hummer M, Fleischhacker WW. Switching between second-generation antipsychotics: why and how? CNS Drugs 2005; 19:27-42. [PMID: 15651903 DOI: 10.2165/00023210-200519010-00003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The introduction of second-generation antipsychotics represents an important advance in the treatment of schizophrenia. Although these drugs are generally very effective, not all patients respond in the same way. Partial response with persistent positive and negative symptoms and residual symptoms may force physicians to change antipsychotic medication. As more and more second-generation antipsychotics are introduced, the need for practical guidelines on switching these medications becomes increasingly important. In this article we provide a short summary of the second-generation antipsychotics, focusing on efficacy, adverse effect profile and safety. Indications for switching antipsychotic medication are outlined, as well as recommendations when switching is disadvantageous. Three basic switching strategies (abrupt, gradual and overlapping switching) and their potential risks and benefits are described. We review the available evidence concerning techniques, problems and consequences when switching from one second-generation antipsychotic agent to another and discuss potential difficulties.
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Affiliation(s)
- Monika Edlinger
- Department of Biological Psychiatry, Innsbruck Medical University, Innsbruck, A-6020, Austria
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Margetić B, Aukst-Margetić B. Neuroleptic malignant syndrome and clozapine withdrawal at the same time? Prog Neuropsychopharmacol Biol Psychiatry 2005; 29:145-7. [PMID: 15610957 DOI: 10.1016/j.pnpbp.2004.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2004] [Indexed: 10/26/2022]
Abstract
The authors report a case of a patient, who in a few days after an abrupt discontinuation of clozapine and haloperidol developed agitated and confused state resembling neuroleptic malignant syndrome (NMS) and clozapine withdrawal symptoms at the same time. Data obtained from family members led to gradual reintroduction of clozapine and to subsequent recovery. The case illustrates the importance for clinicians to be familiar with the variety of discontinuation symptoms, so they can recognize them and offer effective treatment.
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Affiliation(s)
- Branimir Margetić
- Neuropsychiatric Hospital Dr. Ivan Barbot, 44 317 Popovaca, Croatia.
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22
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Abstract
BACKGROUND Atypical antipsychotics are increasingly used in the treatment of diverse psychiatric disorders; however, there is little information on the 'why, when, and how' of switching between the different atypical antipsychotics currently available. OBJECTIVE To review the data on switching and atypical antipsychotics. METHODS A literature search was initially conducted using the key words followed by a search of relevant articles including conference abstracts; relevant pharmaceutical companies were also contacted. RESULTS Clinical trial data are limited in terms of parameters measured, and case reports describe specific problems. Few studies are based on real world populations of psychiatric patients over the long-term. Careful patient and drug selections matched to a carefully supervised and appropriate cross titration based upon the pharmacodynamic and pharmacokinetic properties of all of the drugs involved is important to avoid potential complications such as re-emergence or worsening of psychosis and withdrawal, rebound, and emergent phenomena including new or uncovered side-effects. Psychoeducation and involvement of patients and caregivers in the process are also necessary for a successful switch. CONCLUSION Despite the prevalence of switching in real world clinical practice, there is a paucity of data to guide clinicians with respect to effective and safe strategies. There are no criteria defining a successful switch. With the increasing range and formulations of atypical antipsychotics available, there is a rationale for their early use to avoid the practical problems associated with switching from conventional antipsychotics as well as the opportunity to maintain patients on an optimal atypical antipsychotic monotherapy.
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Affiliation(s)
- Pierre Chue
- 1Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Emmanuel Stip
- 2Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada
| | - Gary Remington
- 3Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lili Kopala
- 4Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Yeh AWC, Lee JWY, Cheng TC, Wen JK, Chen WH. Clozapine Withdrawal Catatonia Associated With Cholinergic and Serotonergic Rebound Hyperactivity. Clin Neuropharmacol 2004; 27:216-8. [PMID: 15602101 DOI: 10.1097/01.wnf.0000145506.99636.1b] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Catatonia as a clozapine withdrawal syndrome has not been well documented. There is only 1 case of excited catatonia described with the diagnosis made according to strict criteria. The authors report a patient who developed a catatonic stuporous state following abrupt discontinuation of clozapine, associated with features of cholinergic and serotonergic hyperactivity. The catatonic state resolved within 1 week with reinstatement of clozapine. It is suggested that serotonergic hyperactivity was involved, contributed by cholinergic rebound, in the pathogenesis of this patient's clozapine withdrawal catatonic syndrome.
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Affiliation(s)
- Andrew Wei-Chiang Yeh
- Department of General and Adolescent Psychiatry, School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
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Abstract
BACKGROUND A converging body of evidence implicates the gamma-aminobutyric acid (GABA) neurotransmitter system in the pathogenesis of schizophrenia. METHODS The authors review neuroscience literature and clinical studies investigating the role of the GABA system in the pathophysiology of schizophrenia. First, a background on the GABA system is provided, including GABA pharmacology and neuroanatomy of GABAergic neurons. Results from basic science schizophrenia animal models and human studies are reviewed. The role of GABA in cognitive dysfunction in schizophrenia is then presented, followed by a discussion of GABAergic compounds used in monotherapy or adjunctively in clinical schizophrenia studies. RESULTS In basic studies, reductions in GABAergic neuronal density and abnormalities in receptors and reuptake sites have been identified in several cortical and subcortical GABA systems. A model has been developed suggesting GABA's role (including GABA-dopamine interactions) in schizophrenia. In several clinical studies, the use of adjunctive GABA agonists was associated with greater improvement in core schizophrenia symptoms. CONCLUSIONS Alterations in the GABA neurotransmitter system are found in clinical and basic neuroscience schizophrenia studies as well as animal models and may be involved in the pathophysiology of schizophrenia. The interaction of GABA with other well-characterized neurotransmitter abnormalities remains to be understood. Future studies should elucidate the potential therapeutic role for GABA ligands in schizophrenia treatment.
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Affiliation(s)
- Adel Wassef
- University of Texas Health Sciences Center, Room 2C-07, Houston-Harris County Psychiatric Center, 2800 South MacGregor Way, Houston, TX 77021, USA.
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de Leon J, Odom-White A, Josiassen RC, Diaz FJ, Cooper TB, Simpson GM. Serum antimuscarinic activity during clozapine treatment. J Clin Psychopharmacol 2003; 23:336-41. [PMID: 12920408 DOI: 10.1097/01.jcp.0000085405.08426.73] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study attempts: (1) to verify that serum antimuscarinic activity is related to clozapine dose, and more importantly to clozapine plasma concentrations; (2) to explore whether norclozapine has serum antimuscarinic activity; (3) to explore whether antimuscarinic activity is related to clozapine side effects; and (4) to compare the serum antimuscarinic activities of clozapine with those of antiparkinsonian drugs and other antipsychotics. In 39 patients participating in a double-blind clozapine study, the [3H]QNB assay was used to measure serum antimuscarinic activity: (1) on baseline medications; (2) after a 4-week haloperidol trial; (3) after a 16-week clozapine trial of either 100, 300, or 600 mg/d; and (4) after 1 or 2 consecutive 16-week clozapine trials with remaining doses in nonresponders. Clozapine levels predicted serum antimuscarinic activity better than clozapine dose. At the end of the 1st clozapine trial, the correlation with the levels explained 69% of the variance of serum antimuscarinic activity (r = 0.83, P < 0.001, N = 34). Clozapine levels were good predictors of serum antimuscarinic activity only in patients taking 300 or 600 mg/d. After correcting for clozapine levels, the within-subject correlation between norclozapine levels and serum antimuscarinic activity was relatively high and significant (r = 0.54, F = 26.7, df = 1.65, P < 0.001). Constipation was significantly associated with higher serum antimuscarinic activity during the 1st clozapine trial. Clozapine was associated with clearly higher antimuscarinic activity than other antipsychotics or low doses of antiparkinsonians. In vitro studies and new clinical studies are needed to verify whether norclozapine may significantly contribute to antimuscarinic activity during clozapine treatment.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center, Eastern State Hospital, 627 West Fourth Street, Lexington, KY 40508, USA.
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26
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Zesiewicz TA, Borra S, Hauser RA. Clozapine withdrawal symptoms in a Parkinson's disease patient. Mov Disord 2002; 17:1365-7. [PMID: 12465085 DOI: 10.1002/mds.10282] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abrupt clozapine withdrawal can cause rebound psychosis and severe somatic symptoms in psychiatric patients. We report on the case of an advanced Parkinson's disease patient who developed myoclonus, tremor, rigidity, hyperreflexia, and stupor after abrupt clozapine withdrawal. The patient's symptoms resolved with treatment with cyproheptadine. This clinical picture suggests serotonergic rebound as an explanation for the patient's symptoms, although other pharmacological mechanisms are possible. Clozapine should be gradually withdrawn over a period of 1 to 2 weeks when possible, and abruptly discontinued only when necessary.
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Affiliation(s)
- Theresa A Zesiewicz
- Department of Neurology, Parkinson's Disease and Movement Disorders Center, University of South Florida and Tampa General Healthcare, Tampa, Florida 33606, USA.
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Malhotra S, Franco K, Tomford JW, Iqbal R. Polyserositis, Acute Withdrawal, and Relapse After Abrupt Clozapine Discontinuation. PSYCHOSOMATICS 2002; 43:418-20. [PMID: 12297612 DOI: 10.1176/appi.psy.43.5.418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shishuka Malhotra
- Department of Psychiatry and Psychology and the Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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28
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Yokota K, Tatebayashi H, Matsuo T, Shoge T, Motomura H, Matsuno T, Fukuda A, Tashiro N. The effects of neuroleptics on the GABA-induced Cl- current in rat dorsal root ganglion neurons: differences between some neuroleptics. Br J Pharmacol 2002; 135:1547-55. [PMID: 11906969 PMCID: PMC1573270 DOI: 10.1038/sj.bjp.0704608] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
1. Several neuroleptics inhibited the 3 microM gamma-aminobutyric acid induced-chloride current (GABA-current) on dissociated rat dorsal root ganglion neurons in whole-cell patch-clamp investigations. 2. The IC(50) for clozapine, zotepine, olanzapine, risperidone and chlorpromazine were 6.95, 18.26, 20.30, 106.01 and 114.56 microM, respectively. The values for the inhibitory effects of neuroleptics on the GABA (3 microM)-current, which were calculated by the fitting Hill's equations where the concentrations represent the mean therapeutic blood concentrations, were ranked clozapine>zotepine>chlorpromazine>olanzapine>risperidone. These inhibitory effects, weighted with the therapeutic concentrations of neuroleptics, were correlated with the clinical incidences of seizure during treatment with neuroleptics. 3. Clozapine reduced the picrotoxin-inhibiton, and may compete with a ligand of the t-butylbicyclophosphorothionate (TBPS) binding site. 4. Haloperidol and quetiapine did not affect the peak amplitude of the GABA (3 microM)-current. However, haloperidol reduced the clozapine-inhibition, and may antagonize ligand binding to TBPS binding site. 5. Neuroleptics including haloperidol and quetiapine enhanced the desensitization of the GABA (3 microM)-current. However, haloperidol and quetiapine at 100 microM inhibited the desensitization at the beginning of application. 6. Blonanserin (AD-5423) at 30 and 50 microM potentiated the GABA (3 microM)-current to 170.1+/-6.9 and 192.0+/-10.6% of the control current, respectively. Blonanserin shifted GABA concentration-response curve leftward. Blonanserin only partly negatively interacted with diazepam. The blonanserin-potentiation was not reversed by flumazenil. Blonanserin is not a benzodiazepine receptor agonist. 7. The various effects of neuroleptics on the GABA-current may be related to the clinical effects including modifying the seizure threshold.
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Affiliation(s)
- Kenjiro Yokota
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan.
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Yu J, Källström L, Wiesel FA, Johnson AE. Neurochemical changes in the entopeduncular nucleus and increased oral behavior in rats treated subchronically with clozapine or haloperidol. Synapse 1999; 34:192-207. [PMID: 10523757 DOI: 10.1002/(sici)1098-2396(19991201)34:3<192::aid-syn4>3.0.co;2-l] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of the present experiment was to test the possibility that atypical antipsychotics and classical antipsychotics differentially regulate specific neurochemical processes within the entopeduncular nucleus. For these experiments, rats were administered clozapine (25 mg/kg), haloperidol (1 mg/kg), or Tween-80 (control) daily for 21 days. Dopamine D(1)-receptor binding was assessed with in vitro receptor autoradiographic methods and the mRNAs corresponding to the two forms of glutamate decarboxylase (glutamate decarboxylase-65 and glutamate decarboxylase-67) were analyzed using in situ hybridization histochemical methods. In addition, vacuous chewing movements (VCM) were measured throughout the drug administration period as a functional indicator of drug action and changes in striatal dopamine D(2)-receptor binding were measured as a positive control for D(2)-receptor antagonist properties of haloperidol and clozapine. In agreement with previous reports, haloperidol increased D(2)-receptor binding throughout the striatum while clozapine had a more limited impact on D(2)-receptors. Behavioral analysis revealed that both haloperidol and clozapine enhanced the display of vacuous chewing movements to a similar extent but with a different postinjection latency. In the entopeduncular nucleus, clozapine increased D(1)-receptor binding compared to controls while haloperidol was without effect. With respect to the regulation of GAD mRNAs, haloperidol increased glutamate decarboxylase-65 and glutamate decarboxylase-67 mRNA levels throughout the entopeduncular nucleus. The effects of clozapine were restricted to increases in glutamate decarboxylase-65 mRNA. These studies show that clozapine and haloperidol, both of which increase the occurrence of VCM, differentially modulate the neurochemistry of the entopeduncular nucleus.
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Affiliation(s)
- J Yu
- Department of Neuroscience, Ullerâker, University Hospital, Uppsala University, SE-750 17 Uppsala, Sweden
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Tollefson GD, Dellva MA, Mattler CA, Kane JM, Wirshing DA, Kinon BJ. Controlled, double-blind investigation of the clozapine discontinuation symptoms with conversion to either olanzapine or placebo. The Collaborative Crossover Study Group. J Clin Psychopharmacol 1999; 19:435-43. [PMID: 10505585 DOI: 10.1097/00004714-199910000-00007] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The abrupt appearance of clozapine discontinuation symptoms represents a particularly unique situation that has not been characterized in a double-blind, placebo-controlled trial. A randomized, double-blind comparison of placebo (N = 53) and olanzapine 10 mg (N = 53) for 3 to 5 days following the abrupt discontinuation of clozapine (< 300 mg/day) was carried out. Subjects were assessed with the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression Scale of Severity, the Montgomery-Asberg Depression Rating Scale (MADRS), and the Mini-Mental State Evaluation. Subsequently both groups received open-label olanzapine (10-25 mg/day) for an additional 9 weeks. Statistically significantly more placebo-treated (24.5%) than olanzapine-treated (7.5%) patients experienced clozapine discontinuation symptoms (p = 0.017). Core symptoms included delusions, hallucinations, hostility, and paranoid reaction and translated into a significantly higher worsening from baseline on the PANSS total, PANSS General Psychopathology subscale, and MADRS among subjects randomly assigned to receive placebo. After open-label treatment with olanzapine for 9 weeks, both groups were clinically stable, suggesting that the discontinuation symptoms were transient. However, subjects who had been randomly assigned to the 3- to 5-day placebo discontinuation segment achieved somewhat less global clinical improvement. Although a pharmacologic interpretation is speculative, evidence of a clozapine discontinuation syndrome was apparent. In most cases, the direct substitution of a pharmacologically similar agent (olanzapine) prevented the syndrome. Clozapine discontinuation or noncompliance should be considered in the differential assessment of an acutely emergent psychosis. The possibility that subjects who experience a clozapine discontinuation syndrome may take longer or are less likely to clinically restabilize warrants further investigation.
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Affiliation(s)
- G D Tollefson
- Psychopharmacology Division, Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana 46285, USA.
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Delassus-Guenault N, Jegouzo A, Odou P, Seguret T, Zangerlin H, Vignole E, Robert H. Clozapine-olanzapine: a potentially dangerous switch. A report of two cases. J Clin Pharm Ther 1999; 24:191-5. [PMID: 10438178 DOI: 10.1046/j.1365-2710.1999.00218.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Withdrawal symptoms associated with switch between two typical antipsychotics are generally rare and mild. In contrast, switching from clozapine to risperidone can be lead to severe withdrawal symptoms. Different pathophysiologic aetiologies have been suggested for explaining these severe symptoms, including cholinergic supersensitivity and rebound. Theoretically, the switch from clozapine to olanzapine should not lead to any problems because those two agents have the same affinity in vitro for muscarinic receptors. OBJECTIVE This study reports two cases of switches from clozapine to olanzapine, in refractory schizophrenic patients, which were associated with severe withdrawal symptoms. RESULTS After the switch, the two patients developed diaphoresis, hypersialorrhea, bronchial obstruction, agitation, anxiety and enuresis. The symptoms were treated with anticholinergic medication and by an increase in dose of olanzapine to 20 mg/day. For one of the patients this treatment led to normalization of secretion. For the other patient, a superinfection leading to a bilateral pneumopathy which required emergency hospitalization in a general hospital was observed. CONCLUSION The symptomatology and the response to treatment lead to the hypothesis of a muscarinic from abrupt weaning. The withdrawal symptoms disappeared rapidly with an increase in olanzapine dosage and with anticholinergic started at the beginning of the switch. We recommend slow clozapine weaning over 3 weeks or more with concurrent anticholinergic treatment.
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Borison RL. Changing antipsychotic medication: guidelines on the transition to treatment with risperidone. The Consensus Study Group on Risperidone Dosing. Clin Ther 1996; 18:592-607; discussion 591. [PMID: 8879889 DOI: 10.1016/s0149-2918(96)80211-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
When treating patients with psychoses, clinicians must often consider changing their treatment from one antipsychotic agent to another. The transition may be necessary because the patient experiences serious side effects or because the existing therapy no longer controls the patient's symptoms. A principal problem in changing antipsychotic agents is the potential for withdrawal symptoms resulting from discontinuation of the existing therapy. These syndromes can manifest as reemergence or worsening of psychosis, rebound or unmasked dyskinesia, and cholinergic-rebound symptoms. Withdrawal signs and symptoms may include insomnia, nausea, vomiting, anxiety, and agitation. When switching a patient to the new antipsychotic agent risperidone, the clinician can keep withdrawal symptoms to a minimum by considering the patient's clinical history and current status. For some patients, abrupt withdrawal of the current antipsychotic may be possible. For others, the dose of the previous medication must be gradually reduced before risperidone is initiated. In many cases, the transition is best made by overlapping the existing therapy and risperidone.
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Affiliation(s)
- R L Borison
- Medical College of Georgia, School of Medicine, Augusta, USA
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