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Li W, Liu Y, Jiang H, Du J, Zhao Y, Du Z, Li S, Wang H. A Case Report of Excessive Use of Clozapine Combined With Clonazepam. Front Psychiatry 2022; 13:831276. [PMID: 35242065 PMCID: PMC8885542 DOI: 10.3389/fpsyt.2022.831276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION For patients with schizophrenia, clozapine (CLZ) in combination with clonazepam (CLNAZ) is one of the viable therapeutic options. We successfully reduced the doses of CLZ and CLNAZ to the safe range of a polydrug abuse patient. As far as we know, this is the first case of this problem. As there are no relevant guidelines to reduce CLZ or CLNAZ, we hope to share this case to provide a reference for the prevention and treatment of similar patients with multidrug abuse. CASE PRESENTATION This case report describes a 46-year-old male with a 24-year history of schizophrenia. His main clinical manifestations are auditory hallucinations, persecutory delusion, and emotional instability. In 2012, the patient started taking rifampicin due to tuberculosis and gradually overused CLZ and CLNAZ. Before admission, he took 1,275 mg of CLZ every day and 26 mg of CLNAZ every night. With the help of Therapeutic Drug Monitoring (TDM) and pharmacogenetic testing, we gradually reduced his daily dose of CLZ and CLNAZ and formulated a more reasonable dosing schedule for him. At the time of discharge, the patient took CLZ 450 mg per day and CLNAZ 2 mg per night, with no obvious symptoms of psychosis. CONCLUSION In the process of drug maintenance treatment of schizophrenia, it is necessary to adopt TDM strategy to reduce and treat the abuse of multiple prescription drugs.
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Affiliation(s)
- Wei Li
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Alzheimer's Disease and Related Disease Center, Shanghai Jiaotong University, Shanghai, China
| | - Yan Liu
- Shanghai Baoshan Mental Health Center, Shanghai, China
| | - Haifeng Jiang
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Mental Health Center Clinical Research Center, Shanghai, China
| | - Jiang Du
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yan Zhao
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zheyi Du
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shuo Li
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Haihong Wang
- Shanghai Mental Health Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Han C, Wang M, He Y. Clinicopathologic characteristics of patients with tuberculosis and schizophrenia. Biosci Trends 2018; 12:442-444. [PMID: 30101834 DOI: 10.5582/bst.2018.01142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The clinicopathologic characteristics of patients with tuberculosis (TB) and schizophrenia are unclear. In order to facilitate early diagnosis and prompt treatment, a retrospective study was conducted in China. Subjects were 54 consecutive patients who were seen between October 2006 and December 2015. Data on demographic characteristics, underlying diseases, clinical features, and outcomes were collected from medical records using a standardized data collection form. Acid-fast bacilli were detected at a rate of 26.9%, a mycobacterial culture was positive at a rate of 35.4%, and a real-time polymerase chain reaction was positive for TB at a rate of 35%. Of the 54 patients, i) 44 (81.5%) had symptoms for at least 2 weeks; ii) 10 (18.5%) were transferred from a local psychiatric hospital, and 23 (42.6%) were transferred at least twice before arriving at this Hospital. Unfortunately, the outcome was not successful in these patients, 18 patients (33.3%) had to be retreated, 7 patients (13.0%) had their care interrupted because their schizophrenia worsened. The current study found that the management of TB in patients with schizophrenia poses several challenges. These include delays in diagnosis and treatment of TB, inefficient strategies for control of TB transmission in psychiatric hospitals, the need for a psychiatrist to be involved in care, and a high rate of retreatment.
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Affiliation(s)
- Chao Han
- Department of Geriatrics, Shandong Mental Health Center
| | - Maoshui Wang
- Department of Lab Medicine, Shandong Provincial Chest Hospital.,Department of Pediatrics, Qilu Hospital, Shandong University
| | - Yu He
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University
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Murray M, Zhang WV, Edwards RJ. Variation in the Response of Clozapine Biotransformation Pathways in Human Hepatic Microsomes to CYP1A2- and CYP3A4-selective Inhibitors. Basic Clin Pharmacol Toxicol 2017; 122:388-395. [PMID: 29155491 DOI: 10.1111/bcpt.12933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/27/2017] [Indexed: 01/17/2023]
Abstract
The atypical antipsychotic agent clozapine (CLZ) is effective in many patients who are resistant to conventional antipsychotic drugs. Cytochromes P450 (CYPs) 1A2 and 3A4 oxidize CLZ to norCLZ and CLZ N-oxide in human liver. Concurrent treatment with inducers and inhibitors of CYP1A2 modulates CLZ elimination that disrupts therapy. Drug-drug interactions involving CYP3A4 are also significant but less predictable. To further characterize the factors underlying these interactions, we used samples from a cohort of human livers to assess variation in CLZ oxidation pathways in relation to intrinsic CYP3A4 and CYP1A2 activities and the effects of the corresponding selective inhibitors ketoconazole (0.2 and 2 μM) and fluvoxamine (1 and 10 μM). The CYP3A4-selective inhibitor ketoconazole (2 μM) impaired CLZ N-oxide formation in all 14 of the livers used in inhibition studies (≥50% inhibition) while the CYP1A2-selective inhibitor fluvoxamine (10 μM) decreased norCLZ formation in nine. Ketoconazole effectively inhibited CLZ metabolism in five of seven livers that catalysed CYP3A4-dependent testosterone 6β-hydroxylation at or above the median rate and in four other livers with lower intrinsic CYP3A4 activity. Similarly, fluvoxamine (10 μM) readily inhibited CLZ oxidation in seven livers with high CYP1A2-mediated 7-ethoxyresorufin O-deethylation activity (at or above the median) and three livers with lower intrinsic CYP1A2 activity. In three livers, CLZ biotransformation was impaired by both ketoconazole and fluvoxamine, consistent with a major role for both CYPs. These findings suggest that the intrinsic activities of CYPs 1A2 and 3A4 are unrelated to the response to CYP-selective inhibitors and that assessment of the activities in vivo may not assist the prediction of drug-drug interactions.
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Affiliation(s)
- Michael Murray
- Pharmacogenomics and Drug Development Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Wei V Zhang
- Pharmacogenomics and Drug Development Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Robert J Edwards
- Centre for Pharmacology and Therapeutics, Imperial College London, London, UK
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Tóth K, Csukly G, Sirok D, Belic A, Kiss Á, Háfra E, Déri M, Menus Á, Bitter I, Monostory K. Potential Role of Patients' CYP3A-Status in Clozapine Pharmacokinetics. Int J Neuropsychopharmacol 2017; 20:529-537. [PMID: 28340122 PMCID: PMC5492788 DOI: 10.1093/ijnp/pyx019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/17/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The atypical antipsychotic clozapine is effective in treatment-resistant schizophrenia; however, the success or failure of clozapine therapy is substantially affected by the variables that impact the clozapine blood concentration. Thus, elucidating the inter-individual differences in clozapine pharmacokinetics can facilitate the personalized therapy. METHODS Since a potential role in clozapine metabolism is assigned to CYP1A2, CYP2C19, CYP2D6 and CYP3A enzymes, the association between the patients' CYP status (CYP genotypes, CYP expression) and clozapine clearance was evaluated in 92 psychiatric patients. RESULTS The patients' CYP2C19 or CYP2D6 genotypes and CYP1A2 expression seemed to have no effect on clozapine serum concentration, whereas CYP3A4 expression significantly influenced the normalized clozapine concentration (185.53±56.53 in low expressers vs 78.05±29.57 or 66.52±0.25 (ng/mL)/(mg/kg) in normal or high expressers, P<.0001), in particular that the patients expressed CYP1A2 at a relatively low level. The functional CYP3A5*1 allele seemed to influence clozapine concentrations in those patients who expressed CYP3A4 at low levels. The dose requirement for the therapeutic concentration of clozapine was substantially lower in low CYP3A4 expresser patients than in normal/high expressers (2.18±0.64 vs 4.98±1.40 mg/kg, P<.0001). Furthermore, significantly higher plasma concentration ratios of norclozapine/clozapine and clozapine N-oxide/clozapine were observed in the patients displaying normal/high CYP3A4 expression than in the low expressers. CONCLUSION Prospective assaying of CYP3A-status (CYP3A4 expression, CYP3A5 genotype) may better identify the patients with higher risk of inefficiency or adverse reactions and may facilitate the improvement of personalized clozapine therapy; however, further clinical studies are required to prove the benefit of CYP3A testing for patients under clozapine therapy.
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Affiliation(s)
- Katalin Tóth
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Gábor Csukly
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Dávid Sirok
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Ales Belic
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Ádám Kiss
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Edit Háfra
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Máté Déri
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Ádám Menus
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - István Bitter
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
| | - Katalin Monostory
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest Hungary (Ms Tóth, Mr Sirok, Mr Kiss, Ms Háfra, Mr Déri, and Dr Monostory); Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest Hungary (Drs Csukly, Menus, and Bitter); Toxi-Coop Toxicological Research Center, Budapest Hungary (Mr Sirok); University of Ljubljana, Ljubljana Slovenia (Dr Belic)
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Gee S, Dixon T, Docherty M, Shergill SS. Optimising plasma levels of clozapine during metabolic interactions: a review and case report with adjunct rifampicin treatment. BMC Psychiatry 2015; 15:195. [PMID: 26265348 PMCID: PMC4542109 DOI: 10.1186/s12888-015-0536-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/18/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Clozapine is the only licensed medication for treatment-resistant schizophrenia. The metabolism of clozapine is affected by multiple pharmacokinetic interactions, so the co-administration of adjunct medications can have a significant clinical effect. The anti- tuberculosis medication rifampicin is a potent inducer of the cytochrome P450 system and therefore can cause a reduction in the plasma concentration of clozapine. There is limited clinical evidence regarding co-administration of these medications; in particular there is a lack of data regarding the effect on plasma clozapine levels, which is the key factor determining clinical efficacy. This is clinically relevant given evidence of an increased risk of tuberculosis in patients with schizophrenia. CASE PRESENTATION We present a case of a 28 year old British man with a diagnosis of schizoaffective disorder who presented with persistent psychotic symptoms. He developed a systemic inflammatory condition, diagnosed as tuberculosis, and was commenced on a six month course of treatment that included rifampicin. This case presents comprehensive data to illustrate the effect on clozapine plasma levels of a complete course of tuberculosis therapy. CONCLUSION This case report provides guidance to clinicians in managing drug interactions between clozapine and rifampicin to enable safe and effective treatment. The co-administration of these medications is likely to increase as the existing underuse of clozapine is recognised whilst the incidence of tuberculosis increases.
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Affiliation(s)
- Siobhan Gee
- Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Monks Orchard Road, Beckenham, BR3 3BX, UK.
| | - Thomas Dixon
- Springfield University Hospital, South West London and St George's Mental Health NHS Trust, 61 Glenburnie Road, London, SW17 7DJ, UK.
| | - Mary Docherty
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Sukhwinder S Shergill
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
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Doherty AM, Kelly J, McDonald C, O'Dywer AM, Keane J, Cooney J. A review of the interplay between tuberculosis and mental health. Gen Hosp Psychiatry 2013; 35:398-406. [PMID: 23660587 DOI: 10.1016/j.genhosppsych.2013.03.018] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/18/2013] [Accepted: 03/26/2013] [Indexed: 01/05/2023]
Abstract
AIMS Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness. METHODS A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data. RESULTS Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns. CONCLUSIONS As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.
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Abstract
BACKGROUND Rifampin is a potent inducer of both cytochrome P-450 oxidative enzymes and the P-glycoprotein transport system. Among numerous well documented, clinically significant interactions, examples include warfarin, oral contraceptives, itraconazole, digoxin, verapamil, simvastatin, and human immunodeficiency virus-related protease inhibitors. Rifabutin reduces serum concentrations of antiretroviral agents, but less so than rifampin. Rifapentine is also an inducer of drug metabolism. METHODS A literature search of English language journals from 2008 to March 2012 was completed using several databases, including PubMed, EMBASE, and SCOPUS. Search terms included rifampin, rifabutin, rifapentine AND drug interactions. FINDINGS Examples of clinically relevant interactions with rifampin demonstrated by recent reports include posaconazole, voriconazole, oxycodone, risperidone, mirodenafil, and ebastine. CONCLUSIONS To avoid a reduced therapeutic response, therapeutic failure, or toxic reactions when rifampin, rifabutin, or rifapentine are added to or discontinued from medication regimens, clinicians need to be aware of these interactions. Recent studies have indicated that other transporter systems play a role in these drug interactions. As reports of rifampin drug interactions continue to grow, this review is a reminder to clinicians to be vigilant.
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