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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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Okada M, Fukuyama K, Shiroyama T, Murata M. A Working Hypothesis Regarding Identical Pathomechanisms between Clinical Efficacy and Adverse Reaction of Clozapine via the Activation of Connexin43. Int J Mol Sci 2020; 21:ijms21197019. [PMID: 32987640 PMCID: PMC7583770 DOI: 10.3390/ijms21197019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Clozapine (CLZ) is an approved antipsychotic agent for the medication of treatment-resistant schizophrenia but is also well known as one of the most toxic antipsychotics. Recently, the World Health Organization’s (WHO) global database (VigiBase) reported the relative lethality of severe adverse reactions of CLZ. Agranulocytosis is the most famous adverse CLZ reaction but is of lesser lethality compared with the other adverse drug reactions of CLZ. Unexpectedly, VigiBase indicated that the prevalence and relative lethality of pneumonia, cardiotoxicity, and seizures associated with CLZ were more serious than that of agranulocytosis. Therefore, haematological monitoring in CLZ patients monitoring system provided success in the prevention of lethal adverse events from CLZ-induced agranulocytosis. Hereafter, psychiatrists must amend the CLZ patients monitoring system to protect patients with treatment-resistant schizophrenia from severe adverse CLZ reactions, such as pneumonia, cardiotoxicity, and seizures, according to the clinical evidence and pathophysiology. In this review, we discuss the mechanisms of clinical efficacy and the adverse reactions of CLZ based on the accumulating pharmacodynamic findings of CLZ, including tripartite synaptic transmission, and we propose suggestions for amending the monitoring and medication of adverse CLZ reactions associated with pneumonia, cardiotoxicity, and seizures.
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Affiliation(s)
- Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
- Correspondence: ; Tel.: +81-59-231-5018
| | - Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Takashi Shiroyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu 514-8507, Japan; (K.F.); (T.S.)
| | - Masahiko Murata
- National Hospital Organization Sakakibara Hospital, 777 Sakakibara, Tsu, Mie 514-1292, Japan;
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Patel RK, Moore AM, Piper S, Sweeney M, Whiskey E, Cole G, Shergill SS, Plymen CM. Clozapine and cardiotoxicity - A guide for psychiatrists written by cardiologists. Psychiatry Res 2019; 282:112491. [PMID: 31351758 DOI: 10.1016/j.psychres.2019.112491] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/20/2019] [Accepted: 07/20/2019] [Indexed: 12/23/2022]
Abstract
This review discusses the rare but potentially life-threatening cardiovascular side-effects of myocarditis and dilated cardiomyopathy associated with the use of Clozapine. The clinical presentation of these conditions is non-specific, making it difficult to both risk-stratify and identify patients who develop these consequences. This review aims to examine the proposed aetiologies, diagnostic approaches and subsequent management strategies of cardiotoxicity associated with clozapine use; offering guidance to psychiatrists and general physicians. Current evidence highlights the importance of accurate diagnosis to prevent premature and unnecessary cessation of clozapine. Guidance on monitoring and reintroduction of the drug is emerging and current practice recommends a combination of regular monitoring of biomarkers and imaging to make a diagnosis of cardiotoxicity although further work is needed to establish evidence-based guidelines.
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Affiliation(s)
- Rishi K Patel
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK.
| | | | - Susan Piper
- Department of Cardiology, King's College Hospital, London, UK
| | - Mark Sweeney
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Graham Cole
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Sukhi S Shergill
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Carla M Plymen
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
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4
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Howell S, Yarovova E, Khwanda A, Rosen SD. Cardiovascular effects of psychotic illnesses and antipsychotic therapy. Heart 2019; 105:1852-1859. [PMID: 31439658 DOI: 10.1136/heartjnl-2017-312107] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/21/2019] [Accepted: 07/29/2019] [Indexed: 11/04/2022] Open
Abstract
Mortality from cardiovascular disease is increased in people with mental health disorders in general and schizophrenia in particular. The causes are multifactorial, but it is known that antipsychotic medication can cause cardiac side-effects beyond the traditional coronary risk factors. Schizophrenia itself is a contributor to an increased risk of cardiovascular mortality via cardiac autonomic dysfunction and a higher prevalence of metabolic syndrome, both contributing to a reduced life expectancy. The pro-arrhythmic impact of traditional antipsychotics, especially via the hERG-potassium channel, has been known for several years. Newer antipsychotics have a reduced pro-arrhythmic profile but might contribute to higher cardiac death rates by worsening the metabolic profile. Clozapine-induced cardiomyopathy, which is dose independent, is a further concern and continuous monitoring of these patients is required. Prophylaxis with angiotensin-converting enzyme inhibitors is currently under review. Overall, management of cardiovascular risk within this population group must be multifaceted and nuanced to allow the most effective treatment of serious mental illness to be conducted within acceptable parameters of cardiovascular risk; some practical measures are presented for the clinical cardiologist.
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Affiliation(s)
- Sandra Howell
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK
| | - Ekaterina Yarovova
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Ahmad Khwanda
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Stuart D Rosen
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK .,Imperial College, National Heart and Lung Institute Division of Cardiovascular Sciences, London, UK
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5
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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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Rohde C, Polcwiartek C, Kragholm K, Ebdrup BH, Siskind D, Nielsen J. Adverse cardiac events in out-patients initiating clozapine treatment: a nationwide register-based study. Acta Psychiatr Scand 2018; 137:47-53. [PMID: 29064084 DOI: 10.1111/acps.12827] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Using national Danish registers, we estimated rates of clozapine-associated cardiac adverse events. Rates of undiagnosed myocarditis were estimated by exploring causes of death after clozapine initiation. METHOD Through nationwide health registers, we identified all out-patients initiating antipsychotic treatment (January 1, 1996-January 1, 2015). Rates of clozapine-associated myocarditis and pericarditis within 2 months from clozapine initiation and rates of cardiomyopathy within 1-2 years from clozapine initiation were compared to rates for other antipsychotics. Mortality within 2 months from clozapine initiation was extracted. RESULTS Three thousand two hundred and sixty-two patients of a total 7932 patients initiated clozapine as out-patients (41.12%). One patient (0.03%) developed myocarditis, and no patients developed pericarditis within 2 months from clozapine initiation. Two (0.06%) and four patients (0.12%) developed cardiomyopathy within 1 and 2 years respectively. Rates were similar for other antipsychotics. Twenty-six patients died within 2 months from clozapine initiation. Pneumonia (23.08%) and stroke (11.54%) were the main causes of death. We estimated the maximum rate of clozapine-associated fatal myocarditis to 0.28%. CONCLUSION Cardiac adverse effects in Danish out-patients initiating clozapine treatment are extremely rare and these rates appear to be comparable to those observed for other antipsychotic drugs.
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Affiliation(s)
- C Rohde
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark.,Psychiatric Research Academy, Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark
| | - C Polcwiartek
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - K Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - B H Ebdrup
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark.,Center for Neuropsychiatric Schizophrenia Research (CNSR), Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Centre Glostrup, Copenhagen University Hospital, Glostrup, Denmark
| | - D Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - J Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.
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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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Swart LE, Koster K, Torn M, Budde RPJ, Uijlings R. Clozapine-induced myocarditis. Schizophr Res 2016; 174:161-164. [PMID: 27112636 DOI: 10.1016/j.schres.2016.04.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Laurens E Swart
- Department of Radiology, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - Kenneth Koster
- Department of Radiology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Marieke Torn
- Department of Cardiology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Ricardo P J Budde
- Department of Radiology, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - Ruben Uijlings
- Department of Cardiology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
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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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Pompili M, Serafini G, Innamorati M, Ambrosi E, Telesforo L, Venturini P, Giordano G, Battuello M, Lester D, Girardi P. Unmet treatment needs in schizophrenia patients: is asenapine a potential therapeutic option? Expert Rev Neurother 2014; 11:989-1006. [DOI: 10.1586/ern.11.82] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ferri N, Siegl P, Corsini A, Herrmann J, Lerman A, Benghozi R. Drug attrition during pre-clinical and clinical development: understanding and managing drug-induced cardiotoxicity. Pharmacol Ther 2013; 138:470-84. [PMID: 23507039 DOI: 10.1016/j.pharmthera.2013.03.005] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 02/19/2013] [Indexed: 02/08/2023]
Abstract
Cardiovascular toxicity remains a major cause of concern during preclinical and clinical development as well as contributing to post-approval withdrawal of medicines. This issue is particularly relevant for anticancer drugs where, the significant improvement in the life expectancies of patients has dramatically extended the use and duration of drug therapies. Nevertheless, cardiotoxicity is also observed with other classes of drugs, including antibiotics, antidepressants, and antipsychotics. This article summarizes the clinical manifestations of drug-induced cardiotoxicity by various cancer chemotherapies and novel drugs for the treatment of other diseases. Furthermore, it presents on overview of biomarker and imaging techniques for the detection of drug-induced cardiotoxicity. Guidelines for the management of patients exposed to drugs with cardiotoxic potential are presented as well as a checklist for collecting information when a safety signal is observed in clinical trials to more effectively assess the risk of cardiotoxicity and manage patient safety.
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Affiliation(s)
- Nicola Ferri
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.
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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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Abstract
Recently, there has been an increased recognition of the association of clozapine with myocarditis and myocardiopathy. Commonly used diagnostic tests have very limited sensitivity in diagnosing this potentially life-threatening complication. We present 3 case reports of clozapine-induced myocarditis/cardiomyopathy that illustrate the development of a combined approach involving a clinical questionnaire and diagnostic testing at our hospital. This combination approach helped in the early recognition and successful treatment of clozapine myocarditis in one of our patients. Given the increasing recognition of this adverse reaction, we felt it timely to report our experience in diagnosing and treating this clinical syndrome.
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Haas SJ, Hill R, Krum H, Liew D, Tonkin A, Demos L, Stephan K, McNeil J. Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993-2003. Drug Saf 2007; 30:47-57. [PMID: 17194170 DOI: 10.2165/00002018-200730010-00005] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Clozapine is an antipsychotic medication associated with a lower suicide rate compared with other antipsychotic agents. Clozapine is used specifically in patients for whom previous therapy was inadequate or not tolerated, and is the only antipsychotic agent associated with the development of myocarditis. OBJECTIVE To retrospectively review all adverse drug reaction reports voluntarily submitted to the Australian Adverse Drug Reactions Unit mentioning suspected myocarditis in clozapine-treated patients. PATIENTS AND METHODS We accessed all electronic database entries and case reports citing suspected myocarditis associated with clozapine therapy from January 1993 through to December 2003, inclusive. RESULTS 116 case reports of suspected myocarditis amongst clozapine-treated patients were identified during the specified time frame (incidence between 0.7% and 1.2% of treated patients). Median patient age for these cases was 30 years (SD 11.1 years) compared with 37 years from the Clopine registry. The condition developed within a median 16 days (mean 19.8 days; SD 17.3 days) of commencing clozapine for the bulk of patients developing myocarditis within 6 months (n=93, 80.2%). For all cases with known treatment commencement and cessation dates (n=106), the condition developed within a median 17 days (mean 171.7 days, SD 530.9 days). Over nine-tenths of cases were prescribed clozapine within the dose range of 100 mg/day to 450 mg/day. Sixty patients (51.8%) recovered from their episode when reported or during follow-up reports, whereas 17 patients (14.7%) had not yet recovered: 27 patients (23.3%) had unknown outcome when reported and the remaining 12 patients (10.3%) died. CONCLUSION Clozapine is uncommonly but importantly related to myocarditis, often fatal or near fatal and sometimes in relatively young patients with early onset after treatment initiation. The most striking feature about this condition is the wide diversity of nonspecific symptoms that occur in afflicted patients. Additional pharmacovigilance, improved reporting systems and further investigation of mechanisms of drug-induced myocarditis and related cardiovascular conditions (such as heart failure) are clearly warranted. A case-control study would be suitable for investigation of baseline predictors.
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Affiliation(s)
- Steven J Haas
- Department of Epidemiology & Preventive Medicine, Faculty of Medicine, Nursing & Health Sciences, Monash University, Alfred Hospital, Melbourne, Victoria, Australia.
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