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Afroz O, Garg S, Kumar A, Kathiresan P, Mishra D, Deep R. Sublingual Atropine Administration for Clozapine-Induced Sialorrhea in Bipolar Disorder: A Case Report Highlighting its Efficacy, Safety Concerns and Challenges. PSYCHOPHARMACOLOGY BULLETIN 2024; 54:124-130. [PMID: 39263201 PMCID: PMC11385264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
We discuss a case with off-label sublingual administration of atropine for clozapine-induced sialorrhea (CIS) after failure of two commonly used agents to manage CIS. Atropine had a demonstrable efficacy, as measured by means of sialometry conducted before and after its administration. The salivary rate, initially measured at 0.60 g/min one hour before atropine administration, reduced to 0.23 g/min two hours after administration. Sublingual administration of atropine was found to be an efficacious option for this patient, but safety issues particularly tachycardia and pragmatics such as risk of inadvertent overdose led to its discontinuation after the initial dose. Developing micro-dosing devices for sublingual atropine could enhance administration precision, reduce side effects, and provide a cost-effective solution. The case report also underscores the need to employ sialometry for the objective assessment of treatment outcomes in future research trials for hypersalivation.
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Affiliation(s)
- Omar Afroz
- Afroz, MD, Psychiatry, Senior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Shaurya Garg
- Garg, MBBS, Junior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar
- Kumar, MBBS, Junior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Preethy Kathiresan
- Kathiresan, MD, Psychiatry, DM, Addiction Psychiatry, Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Deepika Mishra
- Mishra, MDS, Oral Pathology, Additional Professor, Oral Pathology and Microbiology, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
| | - Raman Deep
- Deep, MD, Psychiatry, Professor, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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Arens AM, Sheikh Said H, Driver BE, Cole JB. Physostigmine reversal of delirium from second generation antipsychotic exposure: a retrospective cohort study from a regional poison center. Clin Toxicol (Phila) 2024; 62:463-467. [PMID: 38984853 DOI: 10.1080/15563650.2024.2373850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Physostigmine is an effective antidote for antimuscarinic delirium. There is little evidence for its use to reverse delirium following second generation antipsychotic exposure. The purpose of this study is to describe the safety and effectiveness of physostigmine in reversing delirium from second generation antipsychotic exposure. METHODS This is a retrospective cohort study of all patients reported to a single regional poison center treated with physostigmine following a second generation antipsychotic exposure from January 1, 2000 to April 15, 2021. The poison center electronic medical record was queried to identify cases and for data abstraction. The primary outcome was the positive response rate to physostigmine, as determined by two trained abstractors. Secondary outcomes included physostigmine dosing, and adverse events. RESULTS Of 147 charts reviewed, 138 individual patients were included, and the response to physostigmine was reported in 128 patients. The most common second-generation antipsychotic exposure was quetiapine (97; 70.3 percent). A positive response to physostigmine was noted in 106/128 (82.8 percent) patients [95 percent confidence interval 68.9-83.6 percent]. Median number of physostigmine doses was 1 (interquartile range 1-3; range 1-9). The median total physostigmine dose received was 2 mg (interquartile range 2-6 mg; range 0.15-30 mg). The positive physostigmine response rate for patients with an antimuscarinic co-ingestion was not significantly different compared to patients with a different co-ingestion or no co-ingestion (25/34 versus 81/94; P = 0.09). Adverse events were reported in four (2.9 percent) patients, including one death. DISCUSSION A positive response to physostigmine to treat antimuscarinic delirium from second generation antipsychotic exposure was reported in 82.8 percent of patients, which is similar to previous physostigmine studies. Adverse events were infrequent, and included diaphoresis (one 0.7 percent), seizure (one; 0.7 percent), and bradycardia (one; 0.7 percent). One (0.7%) patient suffered a cardiac arrest 60 minutes after receiving physostigmine to treat antimuscarinic delirium following having received increasing clozapine doses over the previous month. CONCLUSIONS In this study, physostigmine appears to be a safe and effective treatment for antimuscarinic delirium from second generation antipsychotic exposure. Further studies are needed to validate the safety and effectiveness of physostigmine for this indication.
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Affiliation(s)
- Ann M Arens
- MN Regional Poison Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Ochsner Medical Center, New Orleans, LA, USA
| | - Hamdi Sheikh Said
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Jon B Cole
- MN Regional Poison Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024; 23:811-831. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Mutlu E, Özçelik Eroğlu E, Coşkun FÖ, Koçyiğit D, Canpolat İKN, Avcı H, Ertuğrul A, Anıl Yağcıoğlu AE. A systematic chart review of pharmacological interventions in patients with clozapine-induced hypersalivation. Schizophr Res 2024; 268:138-144. [PMID: 37597972 DOI: 10.1016/j.schres.2023.08.004] [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: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES To investigate the efficacy and tolerability of medications, such as mouthwash use of 1 % atropine sulfate and tropicamide drops, oral amitriptyline and amisulpride used for clozapine-induced hypersalivation (CIH). METHODS The medical charts of inpatients with psychotic disorders between 2010 and 2022 were reviewed retrospectively. We detected 161 patients with eligible data who received or commenced clozapine. Primary outcome was defined as the percentage change in the diameter of a wet patch on the pillow (DWP) for improvements in CIH. RESULTS The frequency of CIH was 42 % (n = 68). The first step medications for CIH were tropicamide drops (49 %), atropine drops (43 %) and amitriptyline (3 %). After the first step, the median DWP significantly decreased by -33 %. During the index hospitalization, in 18 patients with persistent CIH, the median DWP significantly decreased by -42 % with the second step medications which also included amisulpride. There were no reported serious adverse events. The change in DWP was significantly correlated with the duration of clozapine treatment (r = 306) and clozapine serum level at discharge (r = 0.294). A linear regression model showed a link between the change in DWP and reduced Positive and Negative Syndrome Scale scores. CONCLUSIONS Our findings emphasize that mouthwash use of atropine or tropicamide drops has a satisfying and tolerable effect in treating CIH. Switching medications for CIH seems to be effective when CIH persists despite a first step agent. Controlled follow-up studies are needed to understand the relationship between CIH, clozapine serum levels, illness severity, and functioning.
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Affiliation(s)
- Emre Mutlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - Elçin Özçelik Eroğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - F Özlem Coşkun
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Doğukan Koçyiğit
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - İrem K N Canpolat
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Hanife Avcı
- Department of Biostatistics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Aygün Ertuğrul
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
| | - A Elif Anıl Yağcıoğlu
- Department of Psychiatry, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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Pagan FL, Schulz PE, Torres-Yaghi Y, Pontone GM. On the Optimal Diagnosis and the Evolving Role of Pimavanserin in Parkinson's Disease Psychosis. CNS Drugs 2024; 38:333-347. [PMID: 38587586 PMCID: PMC11026222 DOI: 10.1007/s40263-024-01084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
Parkinson's disease (PD) is associated with the development of psychosis (PDP), including hallucinations and delusions, in more than half of the patient population. Optimal PD management must therefore involve considerations about both motor and non-motor symptoms. Often, clinicians fail to diagnosis psychosis in patients with PD and, when it is recognized, treat it suboptimally, despite the availability of multiple interventions. In this paper, we provide a summary of the current guidelines and clinical evidence for treating PDP with antipsychotics. We also provide recommendations for diagnosis and follow-up. Finally, an updated treatment algorithm for PDP that incorporates the use of pimavanserin, the only US FDA-approved drug for the treatment of PDP, was developed by extrapolating from a limited evidence base to bridge to clinical practice using expert opinion and experience. Because pimavanserin is only approved for the treatment of PDP in the US, in other parts of the world other recommendations and algorithms must be considered.
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Affiliation(s)
- Fernando L Pagan
- Department of Neurology, Georgetown University Hospital, Washington DC, USA
| | - Paul E Schulz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yasar Torres-Yaghi
- Department of Neurology, Georgetown University Hospital, Washington DC, USA
| | - Gregory M Pontone
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St., Phipps 300, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Puolakka H, Solismaa A, Lyytikäinen LP, Viikki M, Seppälä N, Mononen N, Lehtimäki T, Kampman O. Polymorphisms in ERBB4 and TACR1 associated with dry mouth in clozapine-treated patients. Acta Neuropsychiatr 2024:1-6. [PMID: 38634369 DOI: 10.1017/neu.2024.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Sialorrhea is a common and uncomfortable adverse effect of clozapine, and its severity varies between patients. The aim of the study was to select broadly genes related to the regulation of salivation and study associations between sialorrhea and dry mouth and polymorphisms in the selected genes. METHODS The study population consists of 237 clozapine-treated patients, of which 172 were genotyped. Associations between sialorrhea and dry mouth with age, sex, BMI, smoking, clozapine dose, clozapine and norclozapine serum levels, and other comedication were studied. Genetic associations were analyzed with linear and logistic regression models explaining sialorrhea and dry mouth with each SNP added separately to the model as coefficients. RESULTS Clozapine dose, clozapine or norclozapine concentration and their ratio were not associated with sialorrhea or dryness of mouth. Valproate use (p = 0.013) and use of other antipsychotics (p = 0.015) combined with clozapine were associated with excessive salivation. No associations were found between studied polymorphisms and sialorrhea. In analyses explaining dry mouth with logistic regression with age and sex as coefficients, two proxy-SNPs were associated with dry mouth: epidermal growth factor receptor 4 (ERBB4) rs3942465 (adjusted p = 0.025) and tachykinin receptor 1 (TACR1) rs58933792 (adjusted p = 0.029). CONCLUSION Use of valproate or antipsychotic polypharmacy may increase the risk of sialorrhea. Genetic variations in ERBB4 and TACR1 might contribute to experienced dryness of mouth among patients treated with clozapine.
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Affiliation(s)
- Hanna Puolakka
- Department of Psychiatry, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anssi Solismaa
- Department of Psychiatry, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, The Pirkanmaa Wellbeing Services County, Tampere, Finland
| | - Leo-Pekka Lyytikäinen
- Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Merja Viikki
- Department of Psychiatry, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, The Wellbeing Services County of Ostrobothnia, Seinäjoki, Finland
| | - Niko Seppälä
- Department of Psychiatry, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, Satasairaala Hospital, The Satakunta Wellbeing Services County, Pori, Finland
| | - Nina Mononen
- Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Olli Kampman
- Department of Psychiatry, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, The Pirkanmaa Wellbeing Services County, Tampere, Finland
- Department of Psychiatry, Department of Clinical Sciences (Psychiatry), Faculty of Medicine, University Hospital of Umeå, Umeå University, Umeå, Sweden
- Department of Clinical Medicine (Psychiatry), Faculty of Medicine, University of Turku, Turku, Finland
- Department of Psychiatry, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland
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Mohammad-Gholizad F, Karimzadeh I, Moghimi-Sarani E, Arshadi M, Mortazavi N. Evaluation and Comparison of the Effectiveness of Atropine Eye Drops, Ipratropium Bromide Nasal Spray, and Amitriptyline Tablet in the Management of Clozapine-Associated Sialorrhea in Patients With Refractory Schizophrenia: A Randomized Clinical Trial. J Clin Psychopharmacol 2024; 44:9-15. [PMID: 38100776 DOI: 10.1097/jcp.0000000000001786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
PURPOSE Clozapine, a second-generation antipsychotic medication, is mainly indicated for managing treatment-resistant schizophrenia. Among all the nonthreatening adverse effects of clozapine, sialorrhea is a stigmatizing complication occurring in approximately 31.0% to 97.4% of patients. In this study, 2 topical agents (atropine eye drop and ipratropium nasal spray) and a systemic medication (amitriptyline) were compared simultaneously for the management of clozapine-associated sialorrhea. METHODS We conducted a randomized, single-blinded, non-placebo-controlled clinical trial from June 2022 to January 2023. Eligible patients were randomly allocated into 3 mentioned groups. Patients were monitored for sialorrhea weekly based on scales, including the Toronto Nocturnal Hypersalivation Scale, Clinical Global Impression-Improvement, and Clinical Global Impression-Severity for 1 month. Possible adverse drug reactions and adherence were also recorded. RESULTS Twenty-four patients, including 6, 10, and 8 individuals in ipratropium bromide nasal spray, atropine eye drop, and amitriptyline groups, completed the study, respectively. The cohort's demographic, baseline clinical, and sociocultural characteristics were comparable among the 3 groups. Within-group comparisons, between times baseline and week 4, demonstrated that significant differences were in groups atropine and amitriptyline based on Toronto Nocturnal Hypersalivation Scale, in 3 groups based on Clinical Global Impression-Improvement, and also in only-atropine group based on Clinical Global Impression-Severity. Likewise, between-group comparisons showed that atropine was significantly more effective in clozapine-associated sialorrhea management than amitriptyline and ipratropium, in the first 2 weeks and second 2 weeks of study, respectively. Regarding safety, the interventions were tolerated relatively well. CONCLUSIONS Conclusively, atropine is more efficacious than amitriptyline, within the first 2 weeks of study and also relative to ipratropium, overall. As time effect was significant between atropine and amitriptyline, according to analysis of covariance test, further investigation with longer follow-up duration would be prudent. In addition, expanding patient population with larger sample size should be conducted for more precision.
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Affiliation(s)
| | - Iman Karimzadeh
- From the Department of Clinical Pharmacy, School of Pharmacy
| | - Ebrahim Moghimi-Sarani
- Department of Psychiatry, Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Arshadi
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Negar Mortazavi
- From the Department of Clinical Pharmacy, School of Pharmacy
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Rodulfo A, Goldstein S, Meriden Z. The Challenge of Managing Refractory Psychosis Amid Multiple Medication Side Effects: A Case Report and Review of the Literature. Cureus 2023; 15:e50063. [PMID: 38186486 PMCID: PMC10769498 DOI: 10.7759/cureus.50063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Antipsychotics are the mainstay for the treatment of schizophrenia and other psychotic disorders; however, these agents are associated with an extensive side effect profile that may complicate treatment outcomes. We present the case of a 35-year-old woman with a history of schizoaffective disorder and five prior psychiatric hospitalizations. The patient first presented to the hospital for disorganized behavior, in addition to poor sleep, auditory hallucinations, and racing thoughts in the context of medication nonadherence. She received two loading doses of intra-muscular paliperidone with fair symptomatic improvement. After discharge, she was scheduled to receive a monthly dose of paliperidone, which she missed, resulting in decompensation, re-emergence of psychosis, and another hospitalization two months later. She was given the missed dose with no improvement and progressive deterioration, for which alternative agents were tried. She received olanzapine and was tried briefly on quetiapine and haloperidol as well, with no benefit, and she also developed abnormal perioral movements. She was reloaded with paliperidone, and her psychotic symptoms improved, although she developed akathisia and hyperprolactinemia. The patient returned to the hospital two days later after being discharged, due to disorganized behavior and multiple delusions. Clozapine was started and titrated to 100 mg qam and 200 mg qhs. While on clozapine, she developed profuse sialorrhea that was treated with sublingual atropine drops, and by the time of discharge psychotic symptoms had markedly improved, perioral movements diminished, and prolactin level trended down. The patient maintained stability for over a year after the last admission. Identifying antipsychotics to successfully treat refractory psychosis and managing their multiple potential side effects is challenging but can result in better quality of life for patients as well as improved treatment adherence. This case report is unique in the way it illustrates this point, while discussing different approaches to managing multiple side effects that can happen simultaneously.
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Affiliation(s)
| | | | - Zina Meriden
- Psychiatry, Memorial Regional Hospital, Hollywood, USA
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Berger SJ, Hofer A. [Safety aspects during treatment with clozapine: : Adverse effects, titration, and therapeutic drug monitoring - a narrative review]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2023; 37:122-129. [PMID: 37349671 PMCID: PMC10491532 DOI: 10.1007/s40211-023-00474-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/19/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND According to current guidelines, clozapine should be used as a third step in treatment resistant schizophrenia (TRS). In everyday clinical practice, however, it is frequently used at a much later stage, which leads to a significant deterioration of prognosis. The first part of this narrative overview focuses on the most frequent side effects of clozapine, on the relevance of slow titration, and on specific aspects of therapeutic drug monitoring (TDM). MATERIAL AND METHODS Medline, the Guideline for the use of clozapine 2013 of the Netherlands Clozapine Collaboration Group, and the S3 Guideline for Schizophrenia of the German Association for Psychiatry, Psychotherapy and Psychosomatics were searched for relevant literature, the last query dating from April 28th, 2023. RESULTS Despite its unique efficacy clozapine is underused in clinical practice and prescription varies between and within countries. Next to hematological, metabolic, and vegetative side effects, clozapine induced inflammation manifesting in the form of pneumonia or myocarditis, which is mainly associated with rapid titration, represents a major clinical challenge with CRP monitoring being of particular relevance. In this context, it also has to be noted that sex, smoking behavior, and ethnic origin impact clozapine metabolism, thus requiring personalized dosing. CONCLUSION Slow titration when possible, TDM, and CYP diagnostics when appropriate increase patient safety during treatment with clozapine and thus the likelihood of early prescription of this compound in TRS.
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Affiliation(s)
- Stefan J Berger
- Department für Psychiatrie, Psychotherapie, Psychosomatik und Medizinische Psychologie, Univ.-Klinik für Psychiatrie I, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Alex Hofer
- Department für Psychiatrie, Psychotherapie, Psychosomatik und Medizinische Psychologie, Univ.-Klinik für Psychiatrie I, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Robert A. Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann-Str. 10, D-60528 Frankfurt am Main, Germany
- Ernst Strüngmann Institute (ESI) for Neuroscience in Cooperation with Max Planck Society, Frankfurt am Main, Germany
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Abstract
PURPOSE Hypersalivation is one of the most prevalent and distressing adverse effects associated with clozapine treatment. Currently, there is no standard therapeutic approach toward how to overcome it. Clinicians use various medications for managing this adverse effect. However, some of the agents are not effective enough, whereas others can induce other adverse effects. Recently, several reviews have been published on the treatment of clozapine-associated hypersalivation, in which the focus was on drugs from various pharmacological groups, and little attention was paid to drugs from the group of substituted benzamides. The intention of this brief narrative review is to draw the attention of clinicians to the use of the benzamide group for the treatment of this unpleasant adverse effect. METHODS A MEDLINE search was conducted to identify published treatment studies and case reports in the literature from 2000 to September 2021, concerning a treatment of clozapine-associated hypersalivation, mainly substituted benzamides. RESULTS Accumulating evidence during the last 2 decades indicates that agents derived from the benzamide group may be effective and safe agents for treatment of clozapine-associated hypersalivation. Whether with a psychotropic effect or without, medications from this group may produce a beneficial response. CONCLUSIONS Substitute benzamide derivatives have emerged as effective and well-tolerated agents for treatment clozapine-associated hypersalivation.
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Hurley K, O’Brien S, Halleran C, Byrne D, Foley E, Cunningham J, Hoctor F, Sahm LJ. Metabolic Syndrome in Adults Receiving Clozapine; The Need for Pharmacist Support. PHARMACY 2023; 11:pharmacy11010023. [PMID: 36827661 PMCID: PMC9964454 DOI: 10.3390/pharmacy11010023] [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: 11/23/2022] [Revised: 01/20/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
People who are diagnosed with treatment resistant schizophrenia (TRS) are likely to have clozapine as a therapeutic management option. There is a high prevalence of metabolic syndrome in patients receiving clozapine. To mitigate against this, monitoring of weight, waist circumference, lipid profile, glycated haemoglobin (HbA1c), fasting blood glucose (FBG) and blood pressure (BP) is recommended. The aims of this study were to examine the prevalence of metabolic syndrome and whether any variables were correlated with its development, and to highlight any opportunities for the pharmacist to offer support. This study was conducted in an urban hospital and its associated Clozapine Clinic in Cork, Ireland. A retrospective audit assessed the prevalence of metabolic syndrome using the International Diabetes Federation (IDF) criteria. Patients were eligible for inclusion if they were aged 18 years or more, registered with the Clozapine Clinic, and had the capacity to provide informed consent. All data were entered into Microsoft® Excel ® (Microsoft Corporation) and further statistical analysis was undertaken using R, t-tests, Fisher's Exact Test and Mann-Whitney U tests as appropriate, and p ≤ 0.05 was considered statistically significant. Of 145 patients (32% female; mean age (SD) 45.3 (±11.7) years; 86.2% living independently/in family home), nearly two thirds (n = 86, 59.3%) were diagnosed with metabolic syndrome. The mean age of participants with metabolic syndrome was 44.4 years (SD = 10.8), similar to the 46.6 years (SD = 12.8) for those without. Variables that were identified to be statistically significantly associated with metabolic syndrome included waist circumference, weight, triglycerides, high density lipoprotein-cholesterol (HDL-C), BP, FBG and HbA1c. The high incidence of metabolic syndrome in this patient population highlights the need for continued physical health monitoring of these patients to ameliorate the risk of developing metabolic syndrome.
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Affiliation(s)
- Kathleen Hurley
- Pharmacy Department, Mercy University Hospital, T12 WE28 Cork, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland
- North Lee Mental Health Services (NLMHS), T12 WE28 Cork, Ireland
| | - Sinead O’Brien
- St Mary’s Health Campus, St Mary’s Campus, Gurranabraher, T23 TH9D Cork, Ireland
| | - Ciaran Halleran
- Pharmacy Department, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Derina Byrne
- Pharmacy Department, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Erin Foley
- North Lee Mental Health Services (NLMHS), T12 WE28 Cork, Ireland
| | | | - Fionnuala Hoctor
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland
| | - Laura J. Sahm
- Pharmacy Department, Mercy University Hospital, T12 WE28 Cork, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland
- Correspondence:
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13
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Amano Y, Mazda J, Amano K, Ohi K, Shioiri T. Efficacy of sofpironium bromide gel on clozapine-induced hypersalivation in patients with treatment-resistant schizophrenia: double-blind, controlled crossover study. BJPsych Open 2023; 9:e14. [PMID: 36636808 PMCID: PMC9885354 DOI: 10.1192/bjo.2022.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Hypersalivation is a major side-effect of clozapine in patients with treatment-resistant schizophrenia. AIMS We investigated the efficacy of topical anticholinergic formulation sofpironium bromide gel for improving hypersalivation in patients with treatment-resistant schizophrenia receiving clozapine. METHOD A double-blind, controlled crossover study was conducted with sofpironium bromide gel and a placebo gel to treat clozapine-induced hypersalivation in 16 patients with treatment-resistant schizophrenia. Patients were randomly divided between groups A and B (each n = 8). Group A was treated with sofpironium bromide gel for 6 weeks, followed by a 2-week washout period and 6 weeks of placebo gel, after which they were observed for another 2 weeks. In contrast, group B was treated with placebo gel for 6 weeks, followed by a 2-week washout period, 6 weeks of sofpironium bromide gel and a 2-week observation period. One-minute saliva volume, objective salivation ratings (Drooling Severity and Frequency Scale and Nocturnal Hypersalivation Rating Scale) and subjective salivation ratings (Visual Analogue Scale) were assessed every 2 weeks. RESULTS All patients completed the trials. Three patients reported mild, spontaneously resolved skin itching. Compared with baseline values, the 1-min saliva volumes of both groups were significantly decreased by approximately 30% at the second week of sofpironium bromide gel treatment (P < 0.001), and significantly decreased by >40% at the fourth and sixth weeks of treatment (P < 0.001). The effects were maintained for over 2 weeks even after the treatment was discontinued. CONCLUSIONS We suggest that sofpironium bromide gel is effective in treating clozapine-induced hypersalivation in patients with treatment-resistant schizophrenia.
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Affiliation(s)
- Yuhei Amano
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan; and Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jun Mazda
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan
| | - Koichi Amano
- Anzunokai Kakamigahara Hospital, Kakamigahara, Japan
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toshiki Shioiri
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
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14
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Shad MU. Seventy Years of Antipsychotic Development: A Critical Review. Biomedicines 2023; 11:biomedicines11010130. [PMID: 36672638 PMCID: PMC9856208 DOI: 10.3390/biomedicines11010130] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023] Open
Abstract
Since the mid-1950s discovery of the first effective antipsychotic medications (APM), we have only been able to improve the tolerability but not the overall efficacy of currently available APMs, as reflected by effectiveness trials in Europe and the United States. This inability to develop more effective APMs is attributable to multiple factors, including failure to create and use assessment tools to assess core symptom domains in schizophrenia, move beyond the dopaminergic hypothesis and to develop "me too" drugs, imposing ill-defined research domain criteria, and lacking federal funding for clinical trials. The classification of APMs is also confusing, including second-generation, partial agonists, and multimodal APMs in the same class of APMs, despite significant differences in their mechanisms of action. Other factors stagnating drug development include inadequate sample sizes to address heterogeneity, lack of statistical measures correlating with clinical significance, using the atheoretical basis of psychiatric diagnoses, failure to control placebo response, and high cost of newer and perhaps more tolerable APMs. Furthermore, there has been a failure to develop early predictors of antipsychotic response and various tools to optimize an APM response. Finally, some mental health providers are also responsible for the suboptimal use of APMs, by using excessive maintenance doses, often with irrational polypharmacy, further compromising effectiveness and medication adherence. However, some bright spots in antipsychotic development include improved tolerability of APMs and long-acting injectables to address the high prevalence of medication nonadherence. This review critically reviews 70 years of antipsychotic development, the reasons behind the failure to develop more effective APMs, and suggestions for future direction.
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Affiliation(s)
- Mujeeb U. Shad
- UNLV School of Medicine, University of Nevada, Las Vegas, NV 89154, USA;
- College of Osteopathic Medicine, Touro University Nevada, Las Vegas, NV 89014, USA
- Psychiatry Residency Program, Graduate Medical Education, The Valley Health System, Las Vegas, NV 89118, USA
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15
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Prevalence of clozapine-induced sialorrhea and its effect on quality of life. Psychopharmacology (Berl) 2023; 240:203-211. [PMID: 36538098 DOI: 10.1007/s00213-022-06294-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE Clozapine has proven to be superior to other antipsychotic drugs in the treatment of schizophrenia but is under-prescribed due to its potentially severe side effects. Clozapine-induced sialorrhea (CIS) is a frequent and extremely uncomfortable side effect, which remains understudied. OBJECTIVES To examine the prevalence of diurnal and nocturnal CIS in a sample of patients treated with clozapine, and to evaluate its impact on quality of life. METHODS We conducted a cross-sectional, observational study of 130 patients with schizophrenia spectrum disorders treated with clozapine. The prevalence of CIS was evaluated via specific sialorrhea scales. None of the patients included in the study was receiving a specific treatment for hypersalivation during the study period. Possible associations between sialorrhea and clinical and quality of life variables were analyzed. RESULTS Of 130 subjects, 120 (92.3%) suffered from CIS. Eighty-one (62.31%) suffered from diurnal CIS, 115 (88.56%) from nocturnal CIS, and 85 (65.38%) suffered from both. Significant positive associations between quality of life and diurnal CIS (B = 0.417; p = 2.1e - 6, R2 = 0.156) and nocturnal CIS (B = 0.411; p = 7.7e - 6, R2 = 0.139) were detected. Thirty per cent of the subjects reported a moderate to severe negative impact of sialorrhea on their quality of life. CONCLUSIONS The present study suggests that CIS is highly prevalent in patients with schizophrenia and has an important impact on quality of life in one-third of our sample. Therefore, the inclusion of a systematic evaluation and treatment of CIS in standard clinical practice is highly recommended. TRIAL REGISTRATION Clinical Trials ( https://clinicaltrials.gov ) under reference NCT04197037.
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16
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Alfaifi AA, Althemery AU. Sociodemographic characteristics and health-related quality of life of individuals undergoing antidepressant therapy. Sci Rep 2022; 12:17518. [PMID: 36266422 DOI: 10.1038/s41598-022-22164-6a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 10/11/2022] [Indexed: 05/28/2023] Open
Abstract
An important factor for averting depression and creating awareness about clinical treatment is patient preference. Therefore, investigating health-related quality of life associated with different antidepressants is necessary. A retrospective cohort study was performed using the 2018 Medical Expenditure Panel Survey. The MEPS is a nationally representative database of the civilian and noninstitutionalized population spanning different ages, both sexes, and a wide range of sociodemographic and economic backgrounds. Differences in clinical and sociodemographic characteristics among patients using different antidepressant classes were explored. The differences in Veterans RAND 12-Item Health Survey (VR-12) results among groups were examined. The VR-12 metric was used since it measures a patient's overall perspective of their health. Approximately 34.6 million of the patients reported using at least one antidepressant during 2018. Most patients receiving tricyclic therapy reported substantially better mental HRQoL than patients receiving selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or combination therapy. Patients receiving atypical antidepressants reported substantially better mental HRQoL than those receiving other types of antidepressants. Most patients reported a substantial decline in HRQoL after SNRIs or combination therapy. This study found that HRQoL varied across antidepressant users. Thus, health care providers could benefit from taking into consideration quality of life when prescribing antidepressant agents. Moreover, further research is needed to explore other factors that could contribute to the quality of care for patients with depression.
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Affiliation(s)
- Abdullah A Alfaifi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia.
| | - Abdullah U Althemery
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia
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17
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Alfaifi AA, Althemery AU. Sociodemographic characteristics and health-related quality of life of individuals undergoing antidepressant therapy. Sci Rep 2022; 12:17518. [PMID: 36266422 PMCID: PMC9584901 DOI: 10.1038/s41598-022-22164-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 10/11/2022] [Indexed: 01/12/2023] Open
Abstract
An important factor for averting depression and creating awareness about clinical treatment is patient preference. Therefore, investigating health-related quality of life associated with different antidepressants is necessary. A retrospective cohort study was performed using the 2018 Medical Expenditure Panel Survey. The MEPS is a nationally representative database of the civilian and noninstitutionalized population spanning different ages, both sexes, and a wide range of sociodemographic and economic backgrounds. Differences in clinical and sociodemographic characteristics among patients using different antidepressant classes were explored. The differences in Veterans RAND 12-Item Health Survey (VR-12) results among groups were examined. The VR-12 metric was used since it measures a patient's overall perspective of their health. Approximately 34.6 million of the patients reported using at least one antidepressant during 2018. Most patients receiving tricyclic therapy reported substantially better mental HRQoL than patients receiving selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or combination therapy. Patients receiving atypical antidepressants reported substantially better mental HRQoL than those receiving other types of antidepressants. Most patients reported a substantial decline in HRQoL after SNRIs or combination therapy. This study found that HRQoL varied across antidepressant users. Thus, health care providers could benefit from taking into consideration quality of life when prescribing antidepressant agents. Moreover, further research is needed to explore other factors that could contribute to the quality of care for patients with depression.
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Affiliation(s)
- Abdullah A. Alfaifi
- grid.449553.a0000 0004 0441 5588Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942 Saudi Arabia
| | - Abdullah U. Althemery
- grid.449553.a0000 0004 0441 5588Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942 Saudi Arabia
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18
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Correll CU, Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Seppälä N, Howes OD. A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia. CNS Drugs 2022; 36:659-679. [PMID: 35759211 PMCID: PMC9243911 DOI: 10.1007/s40263-022-00932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.
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Affiliation(s)
- C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea de Bartolomeis
- Section on Clinical Psychiatry and Psychology, Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, University of Naples Federico II, Naples, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Niko Seppälä
- Department of Psychiatry Satasairaala, Harjavalta, Finland
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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19
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Amitriptyline for clozapine-induced hypersalivation: A case series. Schizophr Res 2022; 243:110-111. [PMID: 35255267 DOI: 10.1016/j.schres.2022.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/16/2022] [Accepted: 02/26/2022] [Indexed: 11/23/2022]
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20
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Fahy Y, Dineen B, McDonald C, Hallahan B. The impact of COVID-19 on a cohort of patients treated with clozapine. Ir J Psychol Med 2021; 38:249-257. [PMID: 33818330 PMCID: PMC8185411 DOI: 10.1017/ipm.2021.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/12/2021] [Accepted: 03/30/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To examine the psychological and social impact of the COVID-19 pandemic and its associated restrictions on a cohort of patients with severe and enduring mental illness treated with clozapine. METHODS Semi-structured interviews were conducted with 63 individuals attending a clozapine clinic within the Galway-Roscommon Mental Health Services to determine the impact of COVID-19 restrictions on anxiety and depressive symptoms, social and occupational functioning and quality of life, by utilising Likert scale data. The Beck Anxiety Inventory (BAI) and Hamilton Anxiety Rating Scale (HAM-A) were additionally utilised to measure anxiety symptoms cross-sectionally. RESULTS Anxiety symptoms were low with a median BAI score of 4.0 and HAM-A score of 4.0. Likert scale measurements recorded only a modest adverse impact of COVID-19 restrictions on anxiety and depressive symptoms, quality of life and occupational and social functioning. Free-text comments from patients (n = 55), were grouped into five themes: neutral impact (n = 22), negative psychological impact (n = 13), negative social impact (n = 11), positive psychological impact (n = 5) and media coverage inducing anxiety (n = 4). CONCLUSIONS Three months into the COVID-19 pandemic and its restrictions, the impact on individuals with treatment-resistant psychotic disorders attending a clozapine clinic has been modest, with preliminary evidence demonstrating minimal increases in subjective symptoms of anxiety and reduced social functioning. Reduced social engagements and supports attainable both within the community and from mental health services were noted by some participants.
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Affiliation(s)
- Y. Fahy
- Department of Medicine, Galway University Hospital, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - B. Dineen
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - C. McDonald
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Galway–Roscommon Mental Health Services, University Hospital Galway, Ireland
| | - B. Hallahan
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Galway–Roscommon Mental Health Services, University Hospital Galway, Ireland
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21
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Suhas S, Kumar V, Damodharan D, Sharma P, Rao NP, Varambally S, Venkatasubramanian G, Murthy P, Gangadhar BN. Comment on: "Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation". Clin Pharmacokinet 2021; 60:1073-1075. [PMID: 33899164 DOI: 10.1007/s40262-021-01021-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Satish Suhas
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Vijay Kumar
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India.
| | - Dinakaran Damodharan
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Priyamvada Sharma
- Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Naren P Rao
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Shivarama Varambally
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Ganesan Venkatasubramanian
- Schizophrenia and Metabolic Clinics, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, India
| | - Pratima Murthy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Bangalore N Gangadhar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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22
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Yoshida K, Takeuchi H. Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia. Behav Brain Res 2021; 402:113098. [PMID: 33417992 DOI: 10.1016/j.bbr.2020.113098] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/02/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antipsychotics are a cornerstone of pharmacological treatment of schizophrenia. Improved understanding of the dose-response relationship of antipsychotics in terms of efficacy, adverse effects, and mortality can help to optimize the pharmacological treatment of schizophrenia. METHODS This narrative literature review summarizes current evidence on the relationship of antipsychotic dose with efficacy, adverse effects, and mortality in patients with schizophrenia. RESULTS The efficacy of antipsychotics generally appeared to be highly dose-dependent in the acute phase of schizophrenia, with each antipsychotic having a specific dose-response curve. The presence or absence of dose-dependency and its extent varied according to the type of adverse effect. Parkinsonism, hyperprolactinemia, weight gain, and neurocognitive impairment appeared to be dose-related. The following adverse effects might be at least somewhat dose-dependent: akathisia, tardive dyskinesia, osteoporosis, sexual dysfunction, diabetes mellitus, myocardial infarction, stroke, thromboembolism, QT interval prolongation, anticholinergic adverse effects, somnolence, pneumonia, hip fracture, and neuroleptic malignant syndrome. In contrast, the relationships of antipsychotic dose with dyslipidemia, hypotension, seizure, sialorrhea, and neutropenia and agranulocytosis remained unclear due to mixed findings and/or limited data. Although a higher lifetime cumulative antipsychotic dose might contribute to higher mortality, it is still difficult to conclude whether mortality increases in a dose-dependent manner. CONCLUSION These findings could help clinicians to optimize antipsychotic treatment in patients with schizophrenia by balancing risks and benefits in clinical practice. However, further investigations with larger sample sizes and more robust study designs that focus on each antipsychotic agent are needed.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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23
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Schoretsanitis G, Kuzin M, Kane JM, Hiemke C, Paulzen M, Haen E. Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation. Clin Pharmacokinet 2020; 60:329-335. [PMID: 33000411 DOI: 10.1007/s40262-020-00944-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypersalivation is a common, clozapine-related adverse drug reaction with a serious impact on quality of life. Pharmacokinetic correlates of clozapine-related hypersalivation have evaded attention. The purpose of this study was to compare pharmacokinetic parameters between clozapine-treated patients with vs. without hypersalivation from a large therapeutic drug monitoring database. METHODS Out of a large therapeutic drug monitoring dataset of clozapine-treated patients, we compared a group of patients with hypersalivation (n = 72) and a control group of patients without any adverse reactions in this regard (n = 323). Comparisons included plasma concentrations and concentrations-by-dose as well as demographic characteristics between groups. Post-hoc analyses were performed separately in smokers and non-smokers. We used the non-parametric Mann-Whitney U test and the chi-square test, while effects of confounders were assessed using a bootstrapping analysis of covariance. RESULTS Patients with hypersalivation had higher clozapine plasma concentrations and concentrations-by-dose (p < 0.001 for the Mann-Whitney U test in both cases). Groups did not differ regarding demographic characteristics except for clozapine daily dose and percentage of smokers (p = 0.005 for the Mann-Whitney U test and p = 0.028 for the chi-square test, respectively). There were fewer smokers across patients with hypersalivation compared with patients without and daily doses were higher in patients with hypersalivation. After analysis of covariance, differences remained for both plasma concentrations and concentrations-by-dose (p < 0.001 for both). Post hoc analyses in smokers and non-smokers separately reported similar findings. CONCLUSIONS Elevated clozapine plasma concentrations and higher concentrations-by-dose were observed in patients with hypersalivation. A potential role for therapeutic drug monitoring in the prevention or management of clozapine-related hypersalivation is suggested.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Behavioral Health Pavilion, 7559 263rd Street, Glen Oaks, NY, 11004, USA.
| | - Maxim Kuzin
- Clienia Schloessli, Private Psychiatric Hospital and Academic Teaching Hospital of the University of Zurich, Oetwil Am See, Zurich, Switzerland
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Behavioral Health Pavilion, 7559 263rd Street, Glen Oaks, NY, 11004, USA.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Michael Paulzen
- Alexianer Hospital Aachen, Alexianergraben 33, 52062, Aachen, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA, Translational Brain Medicine, Jülich, Germany
| | - Ekkehard Haen
- Department of Psychiatry and Psychotherapy, Clinical Pharmacology, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
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24
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Gupta S, Khastgir U, Croft M, Roshny S. Management of clozapine-induced sialorrhoea. BJPSYCH ADVANCES 2020. [DOI: 10.1192/bja.2019.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYSialorrhoea (hypersalivation) is a common adverse effect of clozapine. If severe, it can affect patients' quality of life and adherence to the treatment. Clinicians therefore need to proactively manage this effect. At present, no drugs are licensed to manage clozapine-induced sialorrhoea, although there are many off-label treatment options, with variable effectiveness. Anticholinergic medications are commonly prescribed for it, but they have limited effect and can worsen constipation. This article gives a brief overview of other practical and pharmacological management options.
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Chapuis J, Siu-Paredes F, Pavageau C, Amador G, Rude N, Denis F. Anticholinergic Drugs and Oral Health-related Quality of Life in Patients with Schizophrenia: A Pilot Study. Transl Neurosci 2020; 11:10-16. [PMID: 32104590 PMCID: PMC7029653 DOI: 10.1515/tnsci-2020-0003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore, in a sample population of people with schizophrenia (PWS), the role of the anticholinergic burden on the perception of oral health-related quality of life (OHrQoL) in France. METHODS A pilot study was performed between March 2014 and January 2016. PWS were recruited from a population in Côte d'Or department in France. Dental status was investigated using the Decayed, Missing, or Filled Teeth (DMFT) index, the Xerostomia Index (XI), and the Global Oral Health Assessment Index (GOHAI) for OHrQoL. The anticholinergic impregnation score was recorded using the anticholinergic impregnation scale (AIS). RESULTS A sample of 62 people was selected. The DMFT score was 16.5± 8.7, the XI score was 22.9±7.8, the GOHAI score was 43.0±8.8, and the AIS score was 3.1±2.8. In total, 169 drugs were prescribed to the people of our sample, and 114 different anticholinergic drugs were observed. The most frequently used anticholinergic drugs (51.40%), in the study had a low antimuscarinic potency (1 point according to AIS scale). The multiple linear regression model showed that the OHrQoL scores were significantly lower when the DMFT scores, XI score, and anticholinergic scores were high. CONCLUSIONS This pilot study highlighted the potential role of the anticholinergic burden on the OHrQoL of PWS. A study with a validated specific scale for the OHrQoL and a standard anticholinergic burden scale should be conducted to clarify the role of anticholinergic drugs on the OHrQoL for PWS.
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Affiliation(s)
- Justine Chapuis
- University Hospital of Tours ,Odontology Department, 37170Chambray-lès-Tours, France
| | - Francesca Siu-Paredes
- EA 481 Integrative Neurosciences and Clinical. University Hospital of Besançon, 25000Besançon, France
- Université Champagne Ardenne. Faculté d’odontologie de Reims, 51100Reims, France
| | - Claire Pavageau
- University Hospital of Tours. Service d’odontologie du CHU de Tours, 37170Chambray-lès-Tours, France
| | - Gilles Amador
- Université de Nantes, Faculté d'Odontologie de Nantes, 44000Nantes, France
| | - Nathalie Rude
- EA 481 Integrative Neurosciences and Clinical. University Hospital of Besançon, 25000Besançon, France
| | - Frédéric Denis
- University Hospital of Tours ,Odontology Department, 37170Chambray-lès-Tours, France
- Université de Nantes, Faculté d'Odontologie de Nantes, 44000Nantes, France
- EA 75-05 Education, Ethique, Santé. Université de Tours, Faculté de Médecine, 37032Tours, France
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Van der Poorten T, De Hert M. The sublingual use of atropine in the treatment of clozapine-induced sialorrhea: A systematic review. Clin Case Rep 2019; 7:2108-2113. [PMID: 31788260 PMCID: PMC6878073 DOI: 10.1002/ccr3.2431] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/29/2019] [Accepted: 08/06/2019] [Indexed: 12/31/2022] Open
Abstract
Clozapine is considered the golden standard in the treatment of therapy-resistant schizophrenia; however, it associated with bothersome side effects such as sialorrhea. Current evidence suggests that the sublingual use of atropine seems to be safe and effective and could be considered as a first-line treatment of clozapine-induced sialorrhea.
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Affiliation(s)
| | - Marc De Hert
- Department Of NeurosciencesKU LeuvenKortenbergBelgium
- University of AntwerpAntwerpBelgium
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Mohandoss AA, Thavarajah R. Salivary Flow Alteration in Patients Undergoing Treatment for Schizophrenia: Disease-Drug-Target Gene/Protein Association Study for Side-effects. J Oral Biol Craniofac Res 2019; 9:286-293. [PMID: 31289718 PMCID: PMC6593211 DOI: 10.1016/j.jobcr.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/14/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Salivary flow alteration (SA), is a known unwarranted effect of schizophrenic medications. It manifest either as reduced (xerostomia) or increased (sialorrhea) SA, among treated schizophrenic patients. It is believed that the SA is due to action of the drugs/disease process involving the muscarinic receptor-3 to process acetyl choline, the common neurotransmitter. The genetic mediation behind the SA in such patients remains largely unexplored. We aimed to address the same by using curated literary databases to identify such relationship, if any existed. MATERIAL AND METHODS Curated databases of Gene-Disease Association, www.DisGeNet.org and www.networkanalyst.ca were effectively used to identify the probable genes, strength of association and the drug-genes pathway that could be possibly be involved. The genes associated with schizophrenia and SA were analyzed in detail. Protein-Protein interaction (PPI) network proven experimentally in humans were used to identify the missing or unreported links. RESULTS In all 28 genes associated with schizophrenia were linked to SA. The genetic network of schizophrenia and xerostomia involved FGFR2 gene prominently and network module was statistically significant (P = 9.87*10-8) was achieved that had xerostomia as a node, while schizophrenia (P = 0.025) had statistical significance. Sialorrhea had no statistical significance (P = 0.555). When schizophrenia and sialorrhea connections were analyzed for genetic interaction, only gene GCH1 emerged. On combining the three disease entities, the association of TAC1 gene with sialorrhea was also identified. Using PPI, the coordination of CHRM3, TAC1 and GPRASP1 gene were identified. This network involved several genes that has significant influence on calcium signaling pathway (P = 7.74*10-16), cholingeric synapse(P = 6 × 10-4), salivary secretion(P = 4.38*10-3), endocytosis(P = 8.23*10-4), TGFβ signaling pathway(P = 0.0031), gap junction (P = 4.08*10-3) and glutamergic synapse(P = 6.4*10-3). The involvement of G-receptor signaling protein product, GNAQ was established. DISCUSSION AND CONCLUSION The possible genetic pathway of SA in schizophrenic patients are discussed in light of pharmacotherapeutics. Using the knowledge effectively would help to increase the quality of life of schizophrenic besides increasing the understanding to use saliva as a biomarker of prognosis of schizophrenia and its drug effects.
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Affiliation(s)
- Anusa Arunachalam Mohandoss
- Dept of Psychiatry, Shri Satya Sai Medical College and Research Institute, Affiliated to Shri Balaji Vidyapeeth, Ammapettai, Kanchipuram, India
| | - Rooban Thavarajah
- Marundeeshwara Oral Pathology Services and Analytics, B-1, Mistral Apartments, Wipro Street, Shollinganallur, Chennai, 600 119, India
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Qurashi I, Chu S, Drake R, Hartley V, Chaudhry I, Deakin JFW, Husain N. Glycopyrrolate in comparison to hyoscine hydrobromide and placebo in the treatment of hypersalivation induced by clozapine (GOTHIC1): a feasibility study. Pilot Feasibility Stud 2019; 5:79. [PMID: 31236286 PMCID: PMC6580560 DOI: 10.1186/s40814-019-0462-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022] Open
Abstract
Background Clozapine-induced hypersalivation (CIH) is a common side effect of clozapine treatment and is disliked by clozapine patients, potentially threatening adherence to clozapine treatment. We proposed a trial of alternative medications, hyoscine and glycopyrrolate, for the treatment of CIH and the primary objective of the feasibility study was to assess the recruitment and retention of community clozapine patients as well as assess the metrics of the primary hypersalivation measure. Methods This 11-month trial took place in two NHS trusts in northwest UK. Participants were community-dwelling clozapine patients aged 18–65 years who were suffering from CIH, and were recruited from community mental health clinics. They were randomised using a telephone randomisation service to receive either hyoscine (1 week at 0.6 mg daily, 3 weeks at 0.9 mg daily), glycopyrrolate (1 week at 2 mg daily, 3 weeks at 3 mg daily) or placebo. Participants and investigators were blinded to which study arm the participants had been randomised to. We collected data on salivation levels and side effects on a weekly basis and also assessed cognition at the beginning and end of the trial. We also interviewed a sample of participants after the trial to gather information on their experience of having taken part. Results One hundred and thirty-eight potential participants agreed to being contacted by researchers about participation in the trial and of these, 29 participants were randomised. Of these, four participants exited the trial before taking any trial medication, and two participants left the study owing to concerns of side effects. Data from four participants was missing, and complete data was available for 19 participants who completed the trial. The mean recruitment rate overall was 1.3 participants per site per month, and the overall retention rate was 76%. Interview data suggested that participants’ experiences of trial participation were overwhelmingly positive. Conclusions The feasibility study demonstrated that a trial of alternative medications in the treatment of CIH is feasible; patients were willing to be randomised to the trial and retention rate was high. Trial registration ClinicalTrials.gov, NCT02613494, registered 24 November 2015
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Affiliation(s)
- Inti Qurashi
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Maghull, UK.,2Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Simon Chu
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Maghull, UK.,4School of Psychology, University of Central Lancashire, Preston, UK
| | - Richard Drake
- 2Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Victoria Hartley
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Maghull, UK.,4School of Psychology, University of Central Lancashire, Preston, UK
| | - Imran Chaudhry
- 2Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - J F W Deakin
- 2Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Nusrat Husain
- 2Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
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Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia. However, it has a high burden of adverse events, including common adverse events such as sialorrhea. Sialorrhea can lead to severe physical complications such as aspiration pneumonia, as well as psychological complications including embarrassment and low self-esteem. Compromised adherence and treatment discontinuation can occur due to intolerability. There have been no meta-analyses examining strategies to mitigate clozapine-induced sialorrhea. METHODS We systematically searched Chinese and Western research databases for randomised controlled trials examining agents for clozapine-induced sialorrhea. No limit to language or date were applied to the search. Where sufficient data for individual agents was available, pairwise meta-analyses were conducted. Results were provided as risk ratios and number needed to treat. Sensitivity analysis was conducted by study quality. Adverse events were provided as number needed to harm. RESULTS 19 studies provided data for use in the meta-analysis. Improvement in clozapine-induced sialorrhea was seen in meta-analyses of propantheline (studies = 6, risk ratio [RR] 2.38, 95% confidence interval [CI] 1.52-3.73; number needed to treat [NNT] 3, 95% CI 1.9-2.7), diphenhydramine (studies = 5, RR 3.09, 95% CI 2.36-4.03; NNT 2, 95% CI 1.5-2.0), chlorpheniramine (studies = 2, RR 2.37, 95% CI 1.59-3.55; NNT 3, 95% CI 1.6-3.5), and benzamide derivatives (odds ratio [OR] 6.93, 95% CI 3.03-15.86). When meta-analyses were limited to high-quality studies, all these results remained significant. Single studies of benzhexol, cyproheptadine, doxepin and Kongyan Tang showed promise. Propantheline increased rates of constipation with a number needed to harm (NNH) of 9 (95% CI 4.2-204.1). CONCLUSION Clozapine-induced sialorrhea is a potentially serious adverse event. Included studies in this meta-analysis were limited by poor study quality. Diphenhydramine, chlorpheniramine and benzamide derivatives appear to have the best supporting evidence and lowest reported adverse events. Caution should be exercised when using propantheline given its increased risk of constipation.
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Hyoscine for clozapine-induced hypersalivation: a double-blind, randomized, placebo-controlled cross-over trial. Int Clin Psychopharmacol 2019; 34:101-107. [PMID: 30614850 DOI: 10.1097/yic.0000000000000251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Clozapine is the only evidence-based antipsychotic for treatment-resistant schizophrenia. However, it has considerable side effects, limiting its usability and reducing patients' adherence. One of the most common and distressing side effects is hypersalivation, which can be debilitating, stigmatizing and potentially dangerous through its association with aspiration pneumonia. There is a paucity of evidence guiding possible treatment strategies for hypersalivation. This study aims to examine the efficacy of hyoscine (scopolamine) for clozapine-induced hypersalivation. Fourteen inpatients diagnosed with treatment-resistant schizophrenia, treated with clozapine and suffering from hypersalivation were randomized to receive hyoscine 0.3 mg and placebo daily for 4 weeks each in a randomized, double-blind, placebo-controlled cross-over trial. The primary outcome was improvement in the Toronto Nocturnal Hypersalivation Scale. The secondary outcomes were change in the mass of the pillowcase, anxiety, depression and quality of life. Hypersalivation improved significantly with hyoscine over placebo when measured by the Toronto Nocturnal Hypersalivation Scale (odds ratio=0.21, 95% confidence interval: 0.16-0.28, P<0.001). No significant difference was observed in any of the secondary outcomes. This study showed a beneficial effect of hyoscine over placebo for clozapine-induced hypersalivation.
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Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018; 17:341-356. [PMID: 30192094 PMCID: PMC6127750 DOI: 10.1002/wps.20567] [Citation(s) in RCA: 263] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
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Affiliation(s)
- T Scott Stroup
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gray
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Lee H, Scolieri BB, Mullick PK. Learned lessons from patients who take clozapine: A case study. Perspect Psychiatr Care 2018; 54:457-461. [PMID: 28926097 DOI: 10.1111/ppc.12245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 08/08/2017] [Accepted: 09/03/2017] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of this report is to provide clinical strategies to manage patients with schizophrenia taking clozapine. CONCLUSIONS Serious side effects and required blood monitoring impede the use of clozapine, despite the benefits of clozapine for managing psychiatric symptoms. Well-managed patients receiving evidence-based interventions exhibit reduced symptoms, improved functioning, and better adherence to treatment. PRACTICE IMPLICATIONS Preexisting medical conditions should be considered before prescribing clozapine. Ongoing education on medication and mental illness for patients and family members is essential to prepare them for adherence to management plans. Healthcare providers are responsible for monitoring the side effects of clozapine.
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Affiliation(s)
- Heeyoung Lee
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Britney B Scolieri
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Prabir K Mullick
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,P.K. Mullick MD & Associates PC, Pittsburgh, Pennsylvania, USA
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Botulinum toxin: a novel therapy for clozapine-induced sialorrhoea. Psychopharmacology (Berl) 2018; 235:369-371. [PMID: 29196826 DOI: 10.1007/s00213-017-4795-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
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Man WH, Colen-de Koning J, Schulte P, Cahn W, van Haelst I, Heerdink E, Wilting I. Clozapine-induced hypersalivation: the association between quantification, perceived burden and treatment satisfaction reported by patients. Ther Adv Psychopharmacol 2017; 7:209-210. [PMID: 28959433 PMCID: PMC5593216 DOI: 10.1177/2045125317707746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/09/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Wai Hong Man
- Department of Clinical Pharmacy, University Medical Center Utrecht, The Netherlands
| | - Jantine Colen-de Koning
- Department of Clinical Pharmacy, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands, and Department of Clinical Pharmacy, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands
| | - Peter Schulte
- Mental Health Services North-Holland North, Heerhugowaard, The Netherlands
| | - Wiepke Cahn
- Department of Psychiatry, University Medical Center Utrecht, The Netherlands
| | - Ingrid van Haelst
- Department of Clinical Pharmacy, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Eibert Heerdink
- Department of Clinical Pharmacy, University Medical Center Utrecht, The Netherlands, and Department of Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Ingeborg Wilting
- Department of Clinical Pharmacy, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Kaplan J, Schwartz AC, Ward MC. Clozapine-Associated Aspiration Pneumonia: Case Series and Review of the Literature. PSYCHOSOMATICS 2017; 59:199-203. [PMID: 28992957 DOI: 10.1016/j.psym.2017.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan Kaplan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Martha C Ward
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Hallahan B. Metoclopramide may be effective for clozapine-induced hypersalivation. EVIDENCE-BASED MENTAL HEALTH 2016; 19:124. [PMID: 27630220 PMCID: PMC10699518 DOI: 10.1136/eb-2016-102445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 11/04/2022]
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