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Daniel P, Rajaree KM, Rudy L, Jafor S, Prasad S, Avanthika C, Jhaveri S. Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates. Heliyon 2023; 9:e13930. [PMID: 36923851 PMCID: PMC10008991 DOI: 10.1016/j.heliyon.2023.e13930] [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: 06/29/2022] [Revised: 12/17/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed. Methodology An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management. Results The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects. Conclusion Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.
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Affiliation(s)
| | | | - Luna Rudy
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sadeque Jafor
- Al Mostaqbal Hospital, Jeddah, Kingdom of Saudi Arabia
| | - Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, 21018, Vinnytsya, Ukraine
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Clozapine-Associated Myocarditis: A Protocol for Monitoring Upon Clozapine Initiation and Recommendations for How to Conduct a Clozapine Rechallenge. J Clin Psychopharmacol 2021; 41:180-185. [PMID: 33587399 DOI: 10.1097/jcp.0000000000001358] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clozapine is the only medication with Food and Drug Administration approval for treatment-resistant schizophrenia. However, it is underutilized in the United States because of several life-threatening adverse effects, including clozapine-associated myocarditis (CAM), and a limited understanding of how to manage these complications. To date, recommendations for rechallenging patients with CAM that incorporate the cardiac literature or cardioprotective medications have not been developed. FINDINGS In this article, we outline a protocol developed with cardiologists and guided by the cardiac literature that provides direction on how to monitor for the initial development of CAM and how to rechallenge patients with CAM. Furthermore, we present 2 successful cases of clozapine rechallenge that were managed using this protocol. CONCLUSIONS In both cases, the patients showed marked improvement in their psychiatric symptoms and functioning, demonstrating the importance of considering rechallenge in patients after CAM.
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Abstract
PURPOSE/BACKGROUND That clozapine is the only agent with an indication for treatment-resistant schizophrenia presents real challenges if clozapine-related myocarditis (CIM) occurs. Clinicians have chosen to rechallenge with a second trial of clozapine in the face of CIM. However, there is very limited literature of this topic. METHODS/PROCEDURES Three cases who underwent clozapine rechallenge after CIM are reviewed and discussed in the context of existing literature and current recommendations. FINDINGS/RESULTS We present 3 young male patients with schizophrenia and schizoaffective disorder who developed CIM during a first clozapine trial, stopped treatment, and subsequently underwent a second clozapine trial. In all cases, the rechallenge was discontinued owing to suspected CIM. A review of the literature includes reports of both successful and unsuccessful clozapine rechallenges after CIM and suggests certain risk factors. Clozapine rechallenge after CIM may be undertaken, as now occurs on occasion with agranulocytosis, although rates of success may be lower. Any such undertaking calls for education, careful monitoring, cautious titration, and a multidisciplinary approach. The balance of risk versus benefits must be considered, and strategies may include a drug holiday, more frequent monitoring upon reinitiation, and slower titration. IMPLICATIONS/CONCLUSIONS Pressure to undertake a rechallenge reflects clozapine's unique role in treatment-resistant schizophrenia and absence of other comparable options. However, it is not without risk, and more research is needed to understand those at increased risk, as well as established strategies that diminish this.
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Sackey BK, Moore TA, Cupples NL, Gutierrez CA. Clozapine-induced myocarditis: Two case reports and review of clinical presentation and recognition. Ment Health Clin 2018; 8:303-308. [PMID: 30397572 PMCID: PMC6213891 DOI: 10.9740/mhc.2018.11.303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Myocarditis is a potentially fatal cardiac disease marked by inflammation of the heart muscle. With a noted black-box warning, rates of clozapine-induced myocarditis are reportedly as high as 3%. Since the first case of clozapine-induced myocarditis was documented in 1994, more than 250 cases have been described in literature with an approximate 33% case-fatality rate. We report 2 cases of patients with primary psychotic disorders treated with clozapine, who developed signs and symptoms of myocarditis. The first was a 35-year-old white male patient with a primary diagnosis of schizoaffective disorder (bipolar type) who was initiated on clozapine after nonresponse to several therapies. On day 26, the patient was admitted to the emergency department for chest pain presenting with eosinophilia and notable elevations in several biomarkers, including troponin and C-reactive protein. The second patient was a 45-year-old black male who was initiated on clozapine for treatment-resistant schizophrenia. On day 13, the patient reported cardiac-related concerns (tachycardia) and flu-like symptoms resulting in hospitalization. Similarly, this patient demonstrated elevated biomarkers (troponin and creatine kinase). Both patients experienced resolution of symptoms after discontinuation of clozapine. Clozapine was not rechallenged for either patient. Review of literature further elucidates the relationship between clozapine and myocarditis, including potential risk factors, pathophysiology, and symptom presentation. Due to the potentially fatal nature of this condition, clinical vigilance and awareness is warranted upon initiation of clozapine through monitoring of symptoms along with cardiac and inflammatory biomarkers as indicated.
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Affiliation(s)
- Bryan K Sackey
- (Corresponding author) Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas,
| | - Troy A Moore
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Director, American Society of Health-System Pharmacists-Accredited Postgraduate Year 2 Psychiatric Pharmacy Residency Program; Assistant Professor, Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Nicole L Cupples
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas
| | - Cynthia A Gutierrez
- Associate Chief, Clinical Pharmacy Programs and Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Assistant Clinical Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas
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Abstract
BACKGROUND Clozapine is widely prescribed for treatment-refractory schizophrenia, but its use is limited by many potentially life-threatening adverse effects. The risk of rechallenge after these complications has never been comprehensively assessed in controlled studies. Thus, clinical guidelines must rely on the published case reports. The number of such reports is likely to increase over time, and updated analyses of larger samples are needed, as they may lead to changes in clinical guidelines. STUDY QUESTIONS How safe is the clozapine rechallenge after life-threatening adverse effects? STUDY DESIGN The published case reports of clozapine rechallenge were identified in a MEDLINE search. We added 121 cases reported from 2012 through 2017 to the 138 cases reported from 1972 through 2011 analyzed by us in a previous publication. The 95% confidence intervals (CIs) of the successful rechallenge rate were calculated for each adverse effect with at least 5 published case reports. The rechallenge was considered a valid clinical option when the lower end of the CI range was at least 50%. RESULTS A successful outcome was documented in 128/203 patients rechallenged after neutropenia (63.0%, CI, 56.0%-69.6%), 3/17 after agranulocytosis (17.7%, CI, 4.7%-44.2%), 11/17 after myocarditis (64.7%, CI, 38.6%-84.7%), and 7/7 after neuroleptic malignant syndrome (100%, CI, 56.1%-100%). Among the 15 patients with other clozapine-induced adverse effects, the rechallenge was successful in those with eosinophilia, cardiac complications other than myocarditis (QTc prolongation, pericarditis, cardiomyopathy, and atrial flutter), and gastrointestinal hypomotility. The rechallenge failed in patients who had developed pancreatitis or renal insufficiency. CONCLUSION Clozapine rechallenge is a reasonable clinical option after return to baseline for patients who had developed neutropenia and neuroleptic malignant syndrome, but not after agranulocytosis or myocarditis. Data are insufficient to formulate rechallenge guidelines for any other clozapine-related adverse effects.
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Bellissima BL, Tingle MD, Cicović A, Alawami M, Kenedi C. A systematic review of clozapine-induced myocarditis. Int J Cardiol 2018; 259:122-129. [DOI: 10.1016/j.ijcard.2017.12.102] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 12/12/2017] [Accepted: 12/27/2017] [Indexed: 12/11/2022]
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Nguyen B, Du C, Bastiampillai T, Dhillon R, Tibrewal P. Successful clozapine re-challenge following myocarditis. Australas Psychiatry 2017; 25:385-386. [PMID: 28506077 DOI: 10.1177/1039856217707394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore the evidence around clozapine re-challenge following myocarditis. CONCLUSION This case adds to the 17 cases of clozapine re-challenge following myocarditis, of which 71% were successful (12 cases). This demonstrates that re-challenge could be performed safely and effectively in the context of clozapine-induced myocarditis, if accompanied by a strict and rigorous monitoring protocol.
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Affiliation(s)
- Bang Nguyen
- Medical Student, University of Adelaide, Adelaide, SA, Australia
| | - Charles Du
- Medical Student, University of Adelaide, Adelaide, SA, Australia
| | - Tarun Bastiampillai
- Executive Director, Mental Health Strategy, SA Health, Government of South Australia, Adelaide, SA, and; Mental Health Systems Research, Department of Psychiatry, Flinders University, Bedford Park, SA, and; SAHMRI - Mind & Brain Research Fellow
| | - Rohan Dhillon
- Medical Lead, Western Mental Health Services, CALHN, Cramond Clinic, The Queen Elizabeth Hospital, Woodville, SA Australia
| | - Prashant Tibrewal
- Consultant Psychiatrist, Cramond Clinic, The Queen Elizabeth Hospital, Woodville, SA, Australia
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Abstract
Clozapine is exceptionally effective in psychotic disorders and can reduce suicidal risk. Nevertheless, its use is limited due to potentially life-threatening adverse effects, including myocarditis and cardiomyopathy. Given their clinical importance, we systematically reviewed research on adverse cardiac effects of clozapine, aiming to improve estimates of their incidence, summarize features supporting their diagnosis, and evaluate proposed monitoring procedures. Incidence of early (≤2 months) myocarditis ranges from <0.1 to 1.0 % and later (3-12 months) cardiomyopathy about 10 times less. Diagnosis rests on relatively nonspecific symptoms, ECG changes, elevated indices of myocardial damage, cardiac MRI findings, and importantly, echocardiographic evidence of developing ventricular failure. Treatment involves stopping clozapine and empirical applications of steroids, diuretics, beta-blockers, and antiangiotensin agents. Mortality averages approximately 25 %. Safety of clozapine reuse remains uncertain. Systematic studies are needed to improve knowledge of the epidemiology, avoidance, early identification, and treatment of these adverse effects, with effective and practicable monitoring protocols.
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Clozapine-Induced Myocarditis: Prevention and Considerations in Rechallenge. PSYCHOSOMATICS 2015; 56:685-90. [DOI: 10.1016/j.psym.2015.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/26/2015] [Accepted: 07/06/2015] [Indexed: 11/17/2022]
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Ronaldson KJ, Fitzgerald PB, McNeil JJ. Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand 2015; 132:231-40. [PMID: 25865238 DOI: 10.1111/acps.12416] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We review the published cases of clozapine-induced myocarditis and describe reasons for the higher incidence in Australia (>1%) than elsewhere (<0.1%). METHOD Medline was searched to September 2014 using 'clozapine' as the sole term. RESULTS A total of around 250 cases of clozapine-induced myocarditis have been published. Fever among patients commencing clozapine has been reported internationally, and very few of these cases were investigated for myocarditis. The time to onset of fever is consistent with its being part of a prodrome of undiagnosed myocarditis, and the risk factors are similar to those for myocarditis. In more severe cases, clozapine is discontinued, avoiding fatalities which may occur with myocarditis. Furthermore, cases of sudden death and respiratory illness may well have been undiagnosed myocarditis. The diagnosis of myocarditis is confounded by the non-specific nature of the signs and symptoms, and it depends on appropriate investigations being conducted at the time of myocardial involvement or, for fatal cases, the affected area of the myocardium being sampled for histology. CONCLUSION It is likely that the incidence of myocarditis is around 3%. Implementation of monitoring procedures will increase case ascertainment and result in more patients benefiting from this valuable medication.
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Affiliation(s)
- K J Ronaldson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - P B Fitzgerald
- Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred Hospital, Melbourne, VIC, Australia
| | - J J McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Chow V, Feijo I, Trieu J, Starling J, Kritharides L. Successful rechallenge of clozapine therapy following previous clozapine-induced myocarditis confirmed on cardiac MRI. J Child Adolesc Psychopharmacol 2014; 24:99-101. [PMID: 24521168 DOI: 10.1089/cap.2013.0098] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vincent Chow
- 1 Department of Cardiology, Concord Repatriation General Hospital and The University of Sydney , Sydney, Australia
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12
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Ittasakul P, Archer A, Kezman J, Atsariyasing W, Goldman MB. Rapid Re-challenge with Clozapine Following Pronounced Myocarditis in a Treatment-Resistance Schizophrenia Patient. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2013:1-11. [PMID: 24047759 DOI: 10.3371/csrp.itar.091313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Clozapine is an atypical antipsychotic which is often effective in patients who fail to respond to other antipsychotics, but its use carries substantial risk. Myocarditis is one of the life-threatening adverse effects which occurs in about 1% of exposed patients. Re-challenge with clozapine is controversial, particularly shortly after the occurrence of the myocarditis and when there is clear and convincing evidence of cardiac damage. Aggressive use of clozapine, however, may be critical for the recovery of patients early in the course of their illness. Here we report a successful case of clozapine rechallenge following an initial aggressive dosage titration in an inpatient setting.
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Affiliation(s)
- Pichai Ittasakul
- Department of Psychiatry, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Manu P, Sarpal D, Muir O, Kane JM, Correll CU. When can patients with potentially life-threatening adverse effects be rechallenged with clozapine? A systematic review of the published literature. Schizophr Res 2012; 134:180-6. [PMID: 22113154 PMCID: PMC3318984 DOI: 10.1016/j.schres.2011.10.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 10/20/2011] [Accepted: 10/24/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clozapine is widely prescribed for treatment refractory patients with schizophrenia, but its use is limited by potentially life threatening adverse effects. Rechallenge after these complications has been occasionally attempted in patients with severe psychotic symptoms. OBJECTIVE To review the outcome of clozapine rechallenge after potentially life threatening adverse effects. METHODS Electronic, all-language, literature search (1972-2011) followed by demographic and clinical data extraction. The outcome of rechallenge was considered favorable when the lower bound of the 95% confidence interval (CI) of the proportion of patients who could continue clozapine was >50%. RESULTS Altogether, 138 patients (mean age: 36.3years, 65.7% male, 57.6% Caucasian, virtually all with schizophrenia spectrum diagnosis) underwent clozapine rechallenge after developing neutropenia (n=112), agranulocytosis (n=15), neuroleptic malignant syndrome (NMS) (n=5), myocarditis (n=4), pericarditis (n=1) and lupus erythematosus (n=1). Rechallenge strategies were heterogeneous and not systematically evaluated. Clozapine rechallenge was successful in 78/112 patients (69.6%, CI: 60.6-77.4) after neutropenia, 3/15 (20%, CI: 7.1-45.2) after agranulocytosis, 5/5 (100%, CI: 56-100) after NMS, 3/4 (75%, CI: 30-95) after myocarditis, 1/1 after pericarditis, and 0/1 after clozapine-induced lupus. Successfully rechallenged patients were followed for 16-96weeks. None of the rechallenged patients died. CONCLUSIONS Although controlled studies are clearly needed, using a priori, confidence interval-based criteria, case reports/series suggest that in refractory patients who benefited from clozapine, careful rechallenge can be considered after neutropenia and NMS, but not after agranulocytosis and myocarditis.
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Affiliation(s)
- Peter Manu
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Deepak Sarpal
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - Owen Muir
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York
| | - John M. Kane
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore – Long Island Jewish Health System, Glen Oaks, New York,Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra University, Hempstead, New York,Albert Einstein College of Medicine, Bronx, New York
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Layland JJ, Liew D, Prior DL. Clozapine-induced cardiotoxicity: a clinical update. Med J Aust 2009; 190:190-2. [PMID: 19220183 DOI: 10.5694/j.1326-5377.2009.tb02345.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 09/02/2008] [Indexed: 11/17/2022]
Abstract
Clozapine is a valuable drug for patients with treatment-resistant schizophrenia. Myocarditis is the most publicised cardiac complication of clozapine treatment, but cardiomyopathy and pericarditis have also been reported. Myocarditis has heterogeneous and non-specific presenting features, making it difficult to identify patients with clozapine-related myocarditis clinically. A high index of suspicion is required. The gold standard for diagnosis of myocarditis is an endomyocardial biopsy, but this is not a practical initial approach. Transthoracic echocardiography is a valuable, reproducible and widely available tool to assist in diagnosis of clozapine-induced cardiotoxicity. The level of B-type natriuretic peptide, a hormone secreted in response to ventricular wall stress, may be useful for evaluating patients with clozapine-induced cardiac dysfunction and may in the future be useful for screening asymptomatic patients. The mainstay of treatment of clozapine-induced cardiotoxicity is cessation of clozapine and provision of supportive care.
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Sagar R, Berry N, Sadhu R, Mishra S, Kahn DA. Clozapine-induced cardiomyopathy presenting as panic attacks. J Psychiatr Pract 2008; 14:182-5. [PMID: 18520789 DOI: 10.1097/01.pra.0000320119.68928.68] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Rajesh Sagar
- All India Institute of Medical Sciences, New Delhi, India
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Brownlowe K, Sola C. Clozapine Toxicity in Smoking Cessation and With Ciprofloxacin. PSYCHOSOMATICS 2008; 49:176. [DOI: 10.1176/appi.psy.49.2.176] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE A case of acute myocarditis associated with the commencement of clozapine is described, highlighting the onset, course and possible contributing factors. There is an urgent need to raise awareness about this potentially fatal complication of clozapine use. RESULTS A 20-year-old male with schizophrenia developed a sudden onset of myocarditis after commencement of clozapine. The patient recovered with intensive medical support. The symptoms occurred around 2 weeks after starting clozapine in an inpatient setting. Possible contributing factors may have been concomitant antidepressant use and unaccustomed physical activity. CONCLUSIONS Myocarditis is an increasingly recognized complication associated with the use of clozapine. It can be fatal if not recognized and treated early. Considering that clozapine remains the gold standard in treatment of resistant psychosis, there is an urgent need to raise awareness among medical and paramedical staff involved in the care of these patients. There are also implications for recommendations and regulations regarding the use of clozapine.
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Affiliation(s)
- Shivarama Varambally
- Macquarie Hospital, Northern Sydney Central Coast Area Mental Health Service, NSW, Australia
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Rathore S, Masani ND, Callaghan PO. Clozapine-Induced Effuso-Constrictive Pericarditis. Cardiology 2006; 108:183-5. [PMID: 17085936 DOI: 10.1159/000096666] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Accepted: 07/24/2006] [Indexed: 11/19/2022]
Abstract
Clozapine is a widely used antipsychotic medication and is effective against both positive and negative symptoms of schizophrenia. However, clozapine use should be monitored closely due to its side effects profile. The main side effects include cardiorespiratory symptoms, seizures and agranulocytosis. We report a case of effuso-constrictive pericarditis soon after being started on clozapine therapy, whose symptoms improved after discontinuation of clozapine. The literature is reviewed and importance of monitoring is discussed.
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Affiliation(s)
- S Rathore
- The Cardiothoracic Centre, Liverpool, UK.
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Wehmeier PM, Heiser P, Remschmidt H. Myocarditis, pericarditis and cardiomyopathy in patients treated with clozapine. J Clin Pharm Ther 2005; 30:91-6. [PMID: 15659009 DOI: 10.1111/j.1365-2710.2004.00616_1.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clozapine is known to cause cardiac side-effects, including myocarditis, pericarditis and cardiomyopathy. Prompted by a case of clozapine-related pericarditis in our hospital we undertook a review of the literature for reports of myocarditis, pericarditis and cardiomyopathy occurring in patients treated with clozapine. This is the first comprehensive review of the literature on this topic.
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Affiliation(s)
- P M Wehmeier
- Department of Child and Adolescent Psychiatry, Philipps-University, Marburg, Germany
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22
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Abstract
OBJECTIVE To review the published literature on serious adverse cardiac events associated with the atypical antipsychotic agent, clozapine, and to make recommendations for cardiac assessment of candidates for clozapine treatment and for monitoring of cardiac status after treatment is initiated. DATA SOURCES We searched the PubMed and MEDLINE databases for articles published from 1970 to 2004 that contain the keywords "clozapine and myocarditis," "clozapine and cardiomyopathy," "clozapine and cardiotoxicity," "clozapine and sudden death" or "clozapine and mortality." We also manually searched the bibliographies of these articles for related sources. STUDY SELECTION We reviewed the 30 case reports, case series, laboratory and clinical trials, data mining studies, and previous reviews identified by this search. DATA SYNTHESIS Recent evidence suggests that clozapine is associated with a low (0.015% to 0.188%) risk of potentially fatal myocarditis or cardiomyopathy. The drug is not known to be independently associated with pathologic prolongation of the QTc interval, but it may contribute to pathologic QTc prolongation in patients with other risk factors for this condition. CONCLUSIONS The low risk of a serious adverse cardiac event should be outweighed by a reduction in suicide risk for most patients taking clozapine. We provide recommendations for assessing and monitoring cardiac status in patients prior to and after initiation of treatment with clozapine.
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Affiliation(s)
- David B Merrill
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University, New York, NY 10032, USA.
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Reinders J, Parsonage W, Lange D, Potter JM, Plever S. Clozapine-related myocarditis and cardiomyopathy in an Australian metropolitan psychiatric service. Aust N Z J Psychiatry 2004; 38:915-22. [PMID: 15555025 DOI: 10.1080/j.1440-1614.2004.01481.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Myocarditis and cardiomyopathy are rarely reported complications of clozapine treatment. The incidence of clozapine-related myocarditis has been variably reported at between 0.03% and 0.19% of initiations and cardiomyopathy has been reported even less commonly. In our Brisbane-based service, nine of 94 patients initiated on clozapine over the previous 3 years appeared to have experienced myocarditis or cardiomyopathy. The unique co-location of our service with a major cardiothoracic hospital facilitated a review of identified cases to inform decisions regarding clozapine treatment and rechallenge in this service. METHOD Cases were identified by survey of psychiatric and cardiac medical staff at The Prince Charles Hospital and subjected to re-evaluation by a multidiscipline consensus panel. The panel compared cases to international reports and identified the clinical features that supported a diagnosis of clozapine-related myocarditis or cardiomyopathy. RESULTS This process resulted in the stratification of the nine cases into the following categories of diagnostic likelihood: three highly probable, three probable, and two possible cases of clozapine-related myocarditis, and one possible case of clozapine-related cardiomyopathy. Successful clozapine rechallenge/continuation was undertaken in two patients and the panel agreed that this was a viable future option for several other patients. CONCLUSIONS Findings of the panel review supported the initial clinical diagnoses. This confirmed that there was an apparent high incidence of clozapine-related myocarditis within this service, for which there was no clear reason. Mechanisms underlying clozapine-related myocarditis and cardiomyopathy, as well as successful clozapine continuation and rechallenge were considered, but definitive explanations remain unknown. This review highlighted the clinician's role in post-marketing drug surveillance to guide rational management of suspected adverse drug effects.
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Affiliation(s)
- Jonathan Reinders
- Department of Psychiatry, The Prince Charles Hospital Health Service District, Queensland, Australia.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2001; 10:561-76. [PMID: 11828841 DOI: 10.1002/pds.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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