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Islam F, Hain D, Lewis D, Law R, Brown LC, Tanner JA, Müller DJ. Pharmacogenomics of Clozapine-induced agranulocytosis: a systematic review and meta-analysis. THE PHARMACOGENOMICS JOURNAL 2022; 22:230-240. [PMID: 35710824 PMCID: PMC9363274 DOI: 10.1038/s41397-022-00281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/03/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022]
Abstract
Although clozapine is the most effective pharmacotherapy for treatment-resistant schizophrenia, it is under-utilized, and initiation is often delayed. One reason is the occurrence of a potentially fatal adverse reaction, clozapine-induced agranulocytosis (CIA). Identifying genetic variations contributing to CIA would help predict patient risk of developing CIA and personalize treatment. Here, we (1) review existing pharmacogenomic studies of CIA, and (2) conduct meta-analyses to identify targets for clinical implementation. A systematic literature search identified studies that included individuals receiving clozapine who developed CIA and controls who did not. Results showed that individuals carrying the HLA-DRB1*04:02 allele had nearly sixfold (95% CI 2.20–15.80, pcorrected = 0.03) higher odds of CIA with a negative predictive value of 99.3%. Previously unreplicated alleles, TNFb5, HLA-B*59:01, TNFb4, and TNFd3 showed significant associations with CIA after multiple-testing corrections. Our findings suggest that a predictive HLA-DRB1*04:02-based pharmacogenomic test may be promising for clinical implementation but requires further investigation.
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2
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Gurrera RJ, Gearin PF, Love J, Li KJ, Xu A, Donaghey FH, Gerace MR. Recognition and management of clozapine adverse effects: A systematic review and qualitative synthesis. Acta Psychiatr Scand 2022; 145:423-441. [PMID: 35178700 DOI: 10.1111/acps.13406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Clozapine is substantially underutilized in most countries and clinician factors including lack of knowledge and concerns about adverse drug effects (ADEs) contribute strongly to treatment reluctance. The aim of this systematic review was to provide clinicians with a comprehensive information source regarding clozapine ADEs. METHODS PubMed and Embase databases were searched for English language reviews concerned with clozapine ADEs; publications identified by the automated search were manually searched for additional relevant citations. Following exclusion of redundant and irrelevant reports, pertinent information was summarized in evidence tables corresponding to each of six major ADE domains; two authors reviewed all citations for each ADE domain and summarized their content by consensus in the corresponding evidence table. This study was conducted in accordance with PRISMA principles. RESULTS Primary and secondary searches identified a total of 305 unique reports, of which 152 were included in the qualitative synthesis. Most clozapine ADEs emerge within 3 months, and almost all appear within 6 months, after initiation. Notable exceptions are weight gain, diabetic ketoacidosis (DKA), severe clozapine-induced gastrointestinal hypomotility (CIGH), clozapine-induced cardiomyopathy (CICM), seizures, and clozapine-induced neutropenia (CIN). Most clozapine ADEs subside gradually or respond to dose reduction; those that prompt discontinuation generally do not preclude rechallenge. Rechallenge is generally inadvisable for clozapine-induced myocarditis (CIM), CICM, and clozapine-induced agranulocytosis (CIA). Clozapine plasma levels >600-1000 μg/L appear more likely to cause certain ADEs (e.g., seizures) and, although there is no clear toxicity threshold, risk/benefit ratios are generally unfavorable above 1000 μg/L. CONCLUSION Clozapine ADEs rarely require discontinuation.
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Affiliation(s)
- Ronald J Gurrera
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Priya F Gearin
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jonathan Love
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin J Li
- Department of Psychiatry, Kaiser Permanente Fremont Medical Center, Fremont, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | - Ashley Xu
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Faith H Donaghey
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Gerace
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Munir F, Javaid HW, Rana MBM, Shaukat F. Ceftriaxone-Induced Reversible Agranulocytosis: A Case Report and Review of Drug-Induced Agranulocytosis. Cureus 2022; 14:e23226. [PMID: 35449634 PMCID: PMC9012477 DOI: 10.7759/cureus.23226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
Abstract
In the modern era of medicine, agranulocytosis is a rare occurrence. Despite significant improvement in patient survival, it still carries significant mortality. Agranulocytosis is most commonly caused by chemotherapeutic agents and numerous non-chemo drugs. As it can develop anytime during treatment and patients can remain asymptomatic, frequent cell count monitoring is an essential tool to make a timely diagnosis. An appropriate drug switch, work up to rule out infection and granulocyte colony-stimulating factor (G-CSF) injection in high-risk cases is the management. The patient should be kept under observation till the resolution of agranulocytosis. We present a case of ceftriaxone-induced agranulocytosis which was completely reversible upon stoppage of drug and granulocyte colony-stimulating factor administration. The pathogenesis of ceftriaxone-induced agranulocytosis is unknown. It is suggested to occur either by an immunologic mechanism or because of direct drug toxicity.
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Nazir D, Wani ZA, Bukhari F, Dar SA, Kawoosa Y. Socio demographic, clinical, and side effect profile of patients on clozapine in Kashmir, North India. MIDDLE EAST CURRENT PSYCHIATRY 2021. [DOI: 10.1186/s43045-021-00163-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clozapine is an atypical second-generation antipsychotic belonging to the family of dibenzodiazepines. There is lack of literature on clozapine from this part of the world. So, our aim was to study the socio demographic, clinical and side effect profile of patients on clozapine in Kashmir.
Results
The mean age of the study group was 32.6 ± 8.9 years with majority being males (78.4%), unmarried (78.4%), unemployed (77.2%), and belonging to nuclear families (77.2%). Almost half of them resided in urban localities (51.1%) and studied upto middle school (55.7%). Around three- fourth (75%) of the patients had diagnosis of treatment-resistant schizophrenia. The mean dose of clozapine was 338.92 ± 158.11 mgs. Sedation (76.1%), hypersalivation (69.5%), constipation (46.6%), and weight gain (34.1%) were most common side effects noted in patients. 4.5% cases developed seizures while on clozapine. 2.3% patients developed agranulocytosis while 4.5% patients developed neutropenia on clozapine. The neutropenia was more pronounced in patients of schizophrenia with suicidal tendencies with doses of more than 400 mg.
Conclusions
We have used clozapine in a wide range of indications. Our patients seem to tolerate and respond to higher doses of clozapine and the prevalence of blood dyscrasias in our study sample was much higher than the rest of India.
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Chrétien B, Lelong-Boulouard V, Chantepie S, Sassier M, Bertho M, Brazo P, Humbert X, Alexandre J, Fedrizzi S, Dolladille C. Haematologic malignancies associated with clozapine v. all other antipsychotic agents: a pharmacovigilance study in VigiBase ®. Psychol Med 2021; 51:1459-1466. [PMID: 32036793 DOI: 10.1017/s0033291720000161] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clozapine is mainly used in patients with treatment-resistant schizophrenia and may lead to potentially severe haematologic adverse events, such as agranulocytosis. Whether clozapine might be associated with haematologic malignancies is unknown. We aimed to assess the association between haematologic malignancies and clozapine using Vigibase®, the WHO pharmacovigilance database. METHODS We performed a disproportionality analysis to compute reporting odds-ratio adjusted for age, sex and concurrent reporting of antineoplastic/immunomodulating agents (aROR) for clozapine and structurally related drugs (loxapine, olanzapine and quetiapine) compared with other antipsychotic drugs. Cases were malignant lymphoma and leukaemia reports. Non-cases were all other reports including at least one antipsychotic report. RESULTS Of the 140 226 clozapine-associated reports, 493 were malignant lymphoma cases, and 275 were leukaemia cases. Clozapine was significantly associated with malignant lymphoma (aROR 9.14, 95% CI 7.75-10.77) and leukaemia (aROR 3.54, 95% CI 2.97-4.22). Patients suffering from those haematologic malignancies were significantly younger in the clozapine treatment group than patients treated with other medicines (p < 0.001). The median time to onset (available for 212 cases) was 5.1 years (IQR 2.2-9.9) for malignant lymphoma and 2.5 years (IQR 0.6-7.4) for leukaemia. The aROR by quartile of dose of clozapine in patients with haematologic malignancies suggested a dose-dependent association. CONCLUSIONS Clozapine was significantly associated with a pharmacovigilance signal of haematologic malignancies. The risk-benefit balance of clozapine should be carefully assessed in patients with risk factors of haematologic malignancies. Clozapine should be used at the lowest effective posology.
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Affiliation(s)
- Basile Chrétien
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
| | - Véronique Lelong-Boulouard
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Normandie Univ, UNICAEN, UFR Santé, INSERM UMR 1075, COMETE-MOBILITES "Vieillissement, Pathologie, Santé", 14000Caen, France
| | - Sylvain Chantepie
- Department of Clinical Haematology, Caen University Hospital, Caen, F-14000, France
| | - Marion Sassier
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
| | - Mickael Bertho
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
| | - Perrine Brazo
- Department of Psychiatry, Esquirol Center, Caen University Hospital, Caen, F-14000, France
- Normandie Univ, UNICAEN, EA7466, Imagerie et Stratégies Thérapeutiques de la Schizophrénie (ISTS), 14000Caen, France
| | - Xavier Humbert
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
- General Practice Department, Normandie Univ, UNICAEN, 14000Caen, France
- Normandie Univ, UNICAEN, EA4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000Caen, France
| | - Joachim Alexandre
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
- Normandie Univ, UNICAEN, EA4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000Caen, France
| | - Sophie Fedrizzi
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Pharmacovigilance Regional Center, Caen University Hospital, Caen, F-14000, France
- Normandie Univ, UNICAEN, EA4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000Caen, France
| | - Charles Dolladille
- Department of Pharmacology, Caen University Hospital, Caen, F-14000, France
- Normandie Univ, UNICAEN, EA4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000Caen, France
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6
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Considerations of HLA, Renal Failure, Valproic Acid Use, and Current Treatment Guidelines in Clozapine-Induced Agranulocytosis. Case Rep Psychiatry 2021; 2021:8816390. [PMID: 33688445 PMCID: PMC7914079 DOI: 10.1155/2021/8816390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/15/2021] [Accepted: 02/04/2021] [Indexed: 11/26/2022] Open
Abstract
Clozapine, the choice atypical antipsychotic for refractory schizophrenia, schizoaffective disorder, and bipolar disorder, has been shown to reduce positive and negative symptoms of schizophrenia. Clozapine, though beneficial in reducing the need for hospitalization, rehabilitation, and health care costs, is known as a drug of last resort due to its potential adverse event of clozapine-induced agranulocytosis, which holds a case fatality rate between 4.2 and 16%. Herein, we describe a female patient with longstanding schizoaffective disorder and chronic kidney disease who suffered from clozapine-induced agranulocytosis after failing two other atypical antipsychotics. Retrospective considerations of this case and management highlight risk factors such as HLA status, renal failure, and concurrent valproic acid use which presently do not have official screening, guidelines, or restrictions in place when prescribing clozapine. Additionally, there are no specific clozapine-induced agranulocytosis management recommendations such as G-CSF/filgrastim dose, timing of bone marrow aspirate and biopsy, and use of concomitant valproate. We propose that further comprehensive official screening, monitoring, and guidelines in the prescribing of clozapine, and further guidelines in the treatment of clozapine induced agranulocytosis, could increase the cost-effectiveness of clozapine treatment, and decrease the incidence, and morbidity of this feared adverse event.
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Legge SE, Walters JT. Genetics of clozapine-associated neutropenia: recent advances, challenges and future perspective. Pharmacogenomics 2019; 20:279-290. [PMID: 30767710 PMCID: PMC6563116 DOI: 10.2217/pgs-2018-0188] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Clozapine is the only effective antipsychotic for treatment-resistant schizophrenia but remains widely under prescribed, at least in part due to its potential to cause agranulocytosis and neutropenia. In this article, we provide an overview of the current understanding of the genetics of clozapine-associated agranulocytosis and neutropenia. We now know that the genetic etiology of clozapine-associated neutropenia is complex and is likely to involve variants from several genes including HLA-DQB1, HLA-B and SLCO1B3/SLCO1B7. We describe recent findings relating to the Duffy-null genotype and its association with benign neutropenia in individuals with African ancestry. Further advances will come from sequencing studies, large, cross-population studies and in understanding the molecular mechanisms underlying these associations.
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Affiliation(s)
- Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics & Genomics, Division of Psychological Medicine & Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, CF24 4HQ, UK
| | - James Tr Walters
- MRC Centre for Neuropsychiatric Genetics & Genomics, Division of Psychological Medicine & Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, CF24 4HQ, UK
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8
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De Berardis D, Rapini G, Olivieri L, Di Nicola D, Tomasetti C, Valchera A, Fornaro M, Di Fabio F, Perna G, Di Nicola M, Serafini G, Carano A, Pompili M, Vellante F, Orsolini L, Martinotti G, Di Giannantonio M. Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine. Ther Adv Drug Saf 2018; 9:237-256. [PMID: 29796248 PMCID: PMC5956953 DOI: 10.1177/2042098618756261] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/10/2018] [Indexed: 12/15/2022] Open
Abstract
Clozapine, a dibenzodiazepine developed in 1961, is a multireceptorial atypical antipsychotic approved for the treatment of resistant schizophrenia. Since its introduction, it has remained the drug of choice in treatment-resistant schizophrenia, despite a wide range of adverse effects, as it is a very effective drug in everyday clinical practice. However, clozapine is not considered as a top-of-the-line treatment because it may often be difficult for some patients to tolerate as some adverse effects can be particularly bothersome (i.e. sedation, weight gain, sialorrhea etc.) and it has some other potentially dangerous and life-threatening side effects (i.e. myocarditis, seizures, agranulocytosis or granulocytopenia, gastrointestinal hypomotility etc.). As poor treatment adherence in patients with resistant schizophrenia may increase the risk of a psychotic relapse, which may further lead to impaired social and cognitive functioning, psychiatric hospitalizations and increased treatment costs, clozapine adverse effects are a common reason for discontinuing this medication. Therefore, every effort should be made to monitor and minimize these adverse effects in order to improve their early detection and management. The aim of this paper is to briefly summarize and provide an update on major clozapine adverse effects, especially focusing on those that are severe and potentially life threatening, even if most of the latter are relatively uncommon.
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Affiliation(s)
- Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, p.zza Italia 1, 64100 Teramo, Italy
| | - Gabriella Rapini
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Luigi Olivieri
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Domenico Di Nicola
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, ‘G. Mazzini’ Hospital, Teramo, Italy
| | - Carmine Tomasetti
- Polyedra Research Group, Teramo, Italy Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Alessandro Valchera
- Polyedra Research Group, Teramo, Italy Villa S. Giuseppe Hospital, Hermanas Hospitalarias, Ascoli Piceno, Italy
| | - Michele Fornaro
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine ‘Federico II’ Naples, Naples, Italy
| | - Fabio Di Fabio
- Polyedra Research Group, Teramo, Italy Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Giampaolo Perna
- Hermanas Hospitalarias, FoRiPsi, Department of Clinical Neurosciences, Villa San Benedetto Menni, Albese con Cassano, Como, Italy Department of Psychiatry and Neuropsychology, University of Maastricht, Maastricht, The Netherlands Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, University of Miami, Florida, USA
| | - Marco Di Nicola
- Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Alessandro Carano
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital ‘Madonna Del Soccorso’, San Benedetto del Tronto, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Federica Vellante
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Laura Orsolini
- Polyedra Research Group, Teramo, Italy Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, UK
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Science, Chair of Psychiatry, University ‘G. D’Annunzio’, Chieti, Italy
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Girardin FR, Poncet A, Perrier A, Vernaz N, Pletscher M, F Samer C, Lieberman JA, Villard J. Cost-effectiveness of HLA-DQB1/HLA-B pharmacogenetic-guided treatment and blood monitoring in US patients taking clozapine. THE PHARMACOGENOMICS JOURNAL 2018; 19:211-218. [PMID: 29298994 PMCID: PMC6462824 DOI: 10.1038/s41397-017-0004-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/18/2017] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
Abstract
Less than 1% of adult patients with schizophrenia taking clozapine develop agranulocytosis, and most of these cases occur within the first weeks of treatment. The human leukocyte antigen (HLA) region has been associated with genetic susceptibility to clozapine-induced agranulocytosis (single amino acid changes in HLA-DQB1 (126Q) and HLA-B (158T)). The current study aimed to evaluate the cost-effectiveness, from a healthcare provider’s perspective, of an HLA genotype-guided approach in patients with treatment-resistant schizophrenia who were taking clozapine and to compare the results with the current absolute neutrophil count monitoring (ANCM) schemes used in the USA. A semi-Markovian model was developed to simulate the progress of a cohort of adult men and women who received clozapine as a third-line antipsychotic medication. We compared current practices using two genotype-guided strategies: (1) HLA genotyping followed by clozapine, with ANCM only for patients who tested positive for one or both alleles (genotype-guided blood sampling); (2) HLA genotyping followed by clozapine for low-risk patients and alternative antipsychotics for patients who tested positive (clozapine substitution scheme). Up to a decision threshold of $3.9 million per quality-adjusted life-year (90-fold the US gross domestic product per capita), the base-case results indicate that compared with current ANCM, genotype-guided blood sampling prior to clozapine initiation appeared cost-effective for targeted blood monitoring only in patients with HLA susceptibility alleles. Sensitivity analysis demonstrated that at a cost of genotype testing of up to USD700, HLA genotype-guided blood monitoring remained a cost-effective strategy compared with either current ANCM or clozapine substitution.
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Affiliation(s)
- François R Girardin
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, and Clinical Pharmacology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland. .,Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.
| | - Antoine Poncet
- The Clinical Research Centre, Division of Clinical Epidemiology, Department of Health and Community Medicine, University of Geneva and University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Nathalie Vernaz
- Medical Direction, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Finance Direction, University Hospitals and University of Geneva, 1205, Geneva, Switzerland
| | - Mark Pletscher
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, and Clinical Pharmacology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Jeffrey A Lieberman
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Jean Villard
- Division of Nephrology, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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10
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Association of HLA-B and HLA-DRB1 polymorphisms with antithyroid drug-induced agranulocytosis in a Han population from northern China. Sci Rep 2017; 7:11950. [PMID: 28931918 PMCID: PMC5607267 DOI: 10.1038/s41598-017-12350-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/07/2017] [Indexed: 01/15/2023] Open
Abstract
Antithyroid drug (ATD)-induced agranulocytosis is associated with human leukocyte antigen (HLA) and nearby genes in Southeast Asian and European populations. The susceptibility of the Han population from northern China to ATD-induced agranulocytosis has not been reported. We evaluated the associations of genetic variants at the HLA-B and HLA-DRB1 loci and 32 candidate single nucleotide polymorphisms (SNPs) with agranulocytosis in 29 patients with ATD-induced agranulocytosis and in 140 patients with Graves’ disease (GD) as controls. All subjects were of Han descent from northern China. HLA-B*27:05 (P = 1.10 × 10−4), HLA-B*38:02 (P = 2.41 × 10−4) and HLA-DRB1*08:03 (P = 1.57 × 10−3) were susceptibility HLA variants for ATD-induced agranulocytosis. All subjects carrying the HLA-B*27:05 allele had agranulocytosis. The odds ratios (ORs) comparing allele carriers to non-carriers were 66.24 (95% confidence interval (CI): 3.54–1239.66) for HLA-B*27:05, 7.525 (95% CI: 2.294–24.68) for HLA-B*38:02 and 4.316 (95% CI: 1.56–11.93) for HLA-DRB1*08:03. Two SNPs, rs2596487 (OR = 4.196, 95% CI = 2.086–8.441, P = 2.08 × 10−5) and rs2228391 (OR = 3.621, 95% CI = 1.596–8.217, P = 1.2 × 10−3), were independently associated with ATD-induced agranulocytosis. Subjects carrying the ‘A’ allele of rs1811197 or HLA-B*38:02 showed lower minimum granulocyte counts than non-carriers (P = 4.74 × 10−4 and P = 7.39 × 10−4, respectively). Our findings support the association between genetic variations of HLA-B and HLA-DRB1 with ATD-induced agranulocytosis in a Han population from northern China.
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11
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Relation of the Allelic Variants of Multidrug Resistance Gene to Agranulocytosis Associated With Clozapine. J Clin Psychopharmacol 2016; 36:257-61. [PMID: 27043126 DOI: 10.1097/jcp.0000000000000495] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Clozapine use is associated with leukopenia and more rarely agranulocytosis, which may be lethal. The drug and its metabolites are proposed to interact with the multidrug resistance transporter (ABCB1/MDR1) gene product, P-glycoprotein (P-gp). Among various P-glycoprotein genetic polymorphisms, nucleotide changes in exons 26 (C3435T), 21 (G2677T), and 12 (C1236T) have been implicated for changes in pharmacokinetics and pharmacodynamics of many substrate drugs. In this study, we aimed to investigate the association between these specific ABCB1 polymorphisms and clozapine-associated agranulocytosis (CAA). Ten patients with a history of CAA and 91 control patients without a history of CAA, despite 10 years of continuous clozapine use, were included. Patient recruitment and blood sample collection were conducted at the Hacettepe University Faculty of Medicine, Department of Psychiatry, in collaboration with the members of the Schizophrenia and Other Psychotic Disorders Section of the Psychiatric Association of Turkey, working in various psychiatry clinics. After DNA extraction from peripheral blood lymphocytes, genotyping was performed using polymerase chain reaction and endonuclease digestion. Patients with CAA had shorter duration of clozapine use but did not show any significant difference in other clinical, sociodemographic characteristics and in genotypic or allelic distributions of ABCB1 variants and haplotypes compared with control patients. Among the 10 patients with CAA, none carried the ABCB1 all-variant haplotype (TT-TT-TT), whereas the frequency of this haplotype was approximately 12% among the controls. Larger sample size studies and thorough genetic analyses may reveal both genetic risk and protective factors for this serious adverse event.
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Maximizing clozapine utilization while minimizing blood dyscrasias: evaluation of patient demographics and severity of events. Int Clin Psychopharmacol 2016; 31:76-83. [PMID: 26565383 DOI: 10.1097/yic.0000000000000108] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine whether patient characteristics such as age, sex, race/ethnicity, and frequency of monitoring play a role in clozapine-related blood dyscrasias. This study examined all neutropenic events to identify any potential demographic qualities that may pose increased risk to individuals receiving clozapine treatment in accordance with the FDA guidelines released in 2005. These guidelines required the addition of absolute neutrophil count (ANC) tests in addition to white blood cell (WBC) counts to regular monitoring and a reduction in the frequency of testing to once monthly after 1 year of satisfactory WBC counts and ANCs. The previous schedule neither included ANC testing nor allowed for further reductions in the frequency of testing after 1 year, with patients continuing to be tested every 2 weeks indefinitely. This is a retrospective, closed chart review of all patients who received clozapine at the State Psychiatric Center and experienced a leukopenic/neutropenic event and/or who had a substantial drop in WBC/ANC from January 2009 to December 2011. A subset of patients who were identified as achieving 'non-rechallengeable' status with either an ANC and/or WBC threshold value from 2001 to 2014 were also examined. This protocol was approved by the New York State Psychiatric Institute Institutional Review Board. A total of 193 patients were included in the study. Males experienced more total events at 6.4 events per person compared with 5.2 events per woman. White patients had 6.5 total events per person compared with 4.2 total events per Black patient; however, Black patients experienced more moderate leukopenia/granulocytopenia events compared with Whites. Regardless of race or ethnicity, patients in the 40-49-year age range had the most events at 8.1 events per person and also presented with the highest number of moderate leukopenia/granulocytopenia events as did those scheduled for weekly monitoring. Conversely, the majority of patients with no recorded events were female and either 20-29 or 60-69 years of age. In total, 16 patients were exclusively designated as non-rechallengeable from 2001 to 2014 and only had one single blood event prompting this clozapine monitoring status. Of these 16 patient events, seven were White males, eight were White females, and one was a Black female with roughly 40% of those patients in the 50-59-year age group. Currently published predictions on possible demographic risk groups may not reflect clinical experience and may pose unnecessary treatment barriers in the provision of clozapine. Although the healthcare team should be aware of the possible demographic predictors of blood dyscrasias when using clozapine, treatment goals and monitoring strategies must be individualized to ensure successful clozapine therapy.
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Reich M, Kotecki N. Interactions médicamenteuses entre les psychotropes et les thérapies pharmacologiques en oncologie : quelles modalités de prescription ? PSYCHO-ONCOLOGIE 2016. [DOI: 10.1007/s11839-015-0540-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Genetic determinants of antithyroid drug-induced agranulocytosis by human leukocyte antigen genotyping and genome-wide association study. Nat Commun 2015; 6:7633. [PMID: 26151496 PMCID: PMC4506516 DOI: 10.1038/ncomms8633] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/26/2015] [Indexed: 01/01/2023] Open
Abstract
Graves' disease is the leading cause of hyperthyroidism affecting 1.0–1.6% of the population. Antithyroid drugs are the treatment cornerstone, but may cause life-threatening agranulocytosis. Here we conduct a two-stage association study on two separate subject sets (in total 42 agranulocytosis cases and 1,208 Graves' disease controls), using direct human leukocyte antigen genotyping and SNP-based genome-wide association study. We demonstrate HLA-B*38:02 (Armitage trend Pcombined=6.75 × 10−32) and HLA-DRB1*08:03 (Pcombined=1.83 × 10−9) as independent susceptibility loci. The genome-wide association study identifies the same signals. Estimated odds ratios for these two loci comparing effective allele carriers to non-carriers are 21.48 (95% confidence interval=11.13–41.48) and 6.13 (95% confidence interval=3.28–11.46), respectively. Carrying both HLA-B*38:02 and HLA-DRB1*08:03 increases odds ratio to 48.41 (Pcombined=3.32 × 10−21, 95% confidence interval=21.66–108.22). Our results could be useful for antithyroid-induced agranulocytosis and potentially for agranulocytosis caused by other chemicals. Graves' disease is the leading cause of hyperthyroidism but treatment options can cause life-threatening complications. Chen et al. conduct two-stage direct HLA genotyping and genome-wide association studies to identify HLA-B*38:02 and HLA-DRB1*08:03 as major pharmacogenetic determinants.
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Verbelen M, Lewis CM. How close are we to a pharmacogenomic test for clozapine-induced agranulocytosis? Pharmacogenomics 2015; 16:915-7. [PMID: 26122865 DOI: 10.2217/pgs.15.67] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Moira Verbelen
- MRC SGDP Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - Cathryn M Lewis
- MRC SGDP Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.,Department of Medical & Molecular Genetics, King's College London, 8th Floor Tower Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
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Verbelen M, Collier DA, Cohen D, MacCabe JH, Lewis CM. Establishing the characteristics of an effective pharmacogenetic test for clozapine-induced agranulocytosis. THE PHARMACOGENOMICS JOURNAL 2015; 15:461-6. [PMID: 25732907 PMCID: PMC4762904 DOI: 10.1038/tpj.2015.5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/18/2014] [Accepted: 12/19/2014] [Indexed: 12/24/2022]
Abstract
Clozapine is the only evidence-based therapy for treatment-resistant schizophrenia, but it induces agranulocytosis, a rare but potentially fatal haematological adverse reaction, in less than 1% of users. To improve safety, the drug is subject to mandatory haematological monitoring throughout the course of treatment, which is burdensome for the patient and one of the main reasons clozapine is underused. Therefore, a pharmacogenetic test is clinically useful if it identifies a group of patients for whom the agranulocytosis risk is low enough to alleviate monitoring requirements. Assuming a genotypic marker stratifies patients into a high-risk and a low-risk group, we explore the relationship between test sensitivity, group size and agranulocytosis risk. High sensitivity minimizes the agranulocytosis risk in the low-risk group and is essential for clinical utility, in particular in combination with a small high-risk group.
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Affiliation(s)
- M Verbelen
- SGDP Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - D A Collier
- SGDP Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Discovery Neuroscience Research, Eli Lilly and Company Ltd, Lilly Research Laboratories, Erl Wood Manor, Surrey, UK
| | - D Cohen
- Department of Severe Mental Illness, Mental Health Care Organization North-Holland North, Heerhugowaard, The Netherlands
| | - J H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C M Lewis
- SGDP Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Department of Medical and Molecular Genetics, King's College London, London, UK
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Clozapine-Induced Late Agranulocytosis and Severe Neutropenia Complicated with Streptococcus pneumonia, Venous Thromboembolism, and Allergic Vasculitis in Treatment-Resistant Female Psychosis. Case Rep Med 2015; 2015:703218. [PMID: 25755670 PMCID: PMC4338390 DOI: 10.1155/2015/703218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/27/2015] [Indexed: 12/03/2022] Open
Abstract
Clozapine is a second-generation antipsychotic agent from the benzodiazepine group indicated for treatment-resistant schizophrenia and other psychotic conditions. Using clozapine earlier on once a case appears to be refractory limits both social and personal morbidity of chronic psychosis. However treatment with second-generation antipsychotics is often complicated by adverse effects. We present a case of a 33-year-old Caucasian woman with a 25-year history of refractory psychotic mania after switching to a 2-year clozapine therapy. She presented clozapine-induced absolute neutropenia, agranulocytosis, which were complicated by Streptococcus pneumonia and sepsis. Clozapine-induced thromboembolism of the common femoral and right proximal iliac vein, as well as allergic vasculitis, was diagnosed. She achieved full remission on granulocyte-colony stimulating factor and specific antibiotic treatment. Early detection of severe clozapine-induced absolute neutropenia and agranulocytosis enabled the effective treatment of two among its most severe complications. Additional evidence to the previously reported possible causal relation between clozapine and venous thromboembolism is offered. Finally, clozapine-induced allergic vasculitis is confirmed as a late adverse effect of clozapine therapy.
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Multiple antipsychotic induced neutropenia—a possible genetic association. Asian J Psychiatr 2014; 11:81. [PMID: 25453707 DOI: 10.1016/j.ajp.2014.06.009] [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: 05/08/2014] [Revised: 06/12/2014] [Accepted: 06/14/2014] [Indexed: 11/20/2022]
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Abanmy NO, Al-Jaloud A, Al-Jabr A, Al-Ruwaisan R, Al-Saeed W, Fatani S. Clozapine-induced blood dyscrasias in Saudi Arab patients. Int J Clin Pharm 2014; 36:815-20. [DOI: 10.1007/s11096-014-9967-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 05/31/2014] [Indexed: 12/17/2022]
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Brandl EJ, Kennedy JL, Müller DJ. Pharmacogenetics of antipsychotics. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:76-88. [PMID: 24881126 PMCID: PMC4079237 DOI: 10.1177/070674371405900203] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE During the past decades, increasing efforts have been invested in studies to unravel the influence of genetic factors on antipsychotic (AP) dosage, treatment response, and occurrence of adverse effects. These studies aimed to improve clinical care by predicting outcome of treatment with APs and thus allowing for individualized treatment strategies. We highlight most important findings obtained through both candidate gene and genome-wide association studies, including pharmacokinetic and pharmacodynamic factors. METHODS We reviewed studies on pharmacogenetics of AP response and adverse effects published on PubMed until early 2012. Owing to the high number of published studies, we focused our review on findings that have been replicated in independent studies or are supported by meta-analyses. RESULTS Most robust findings were reported for associations between polymorphisms of the cytochrome P450 system, the dopamine and the serotonin transmitter systems, and dosage, treatment response, and adverse effects, such as AP-induced weight gain or tardive dyskinesia. These associations were either detected for specific medications or for classes of APs. CONCLUSION First promising and robust results show that pharmacogenetics bear promise for a widespread use in future clinical practice. This will likely be achieved by developing algorithms that will include many genetic variants. However, further investigation is warranted to replicate and validate previous findings, as well as to identify new genetic variants involved in AP response and for replication of existing findings.
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Affiliation(s)
- Eva J Brandl
- Postdoctoral Research Fellow, Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario
| | - James L Kennedy
- Head, Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario; Director, Neuroscience Research Department, Neuroscience Department, CAMH, Toronto, Ontario; l'Anson Professor of Psychiatry and Medical Science, University of Toronto, Toronto, Ontario
| | - Daniel J Müller
- Head, Pharmacogenetics Research Clinic, Neurogenetics Section, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario; Associate Professor, University of Toronto, Toronto, Ontario
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Tsermpini EE, Assimakopoulos K, Bartsakoulia M, Iconomou G, Papadima EM, Mitropoulos K, Squassina A, Patrinos GP. Individualizing clozapine and risperidone treatment for schizophrenia patients. Pharmacogenomics 2014; 15:95-110. [DOI: 10.2217/pgs.13.219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Schizophrenia is a severe disorder that significantly affects the quality of life and total functioning of patients and their caregivers. Clozapine is the first atypical antipsychotic with fewer adverse effects and established efficacy. As a rule of thumb, risperidone is one of the most reliable and effective antipsychotics for newly diagnosed and chronic schizophrenics. Pharmacogenetic studies have identified genomic variants of candidate genes that seem to be important in the way a patient responds to treatment. The recent progress made in pharmacogenomics will improve the quality of treatment, since drug doses will be tailored to the special needs of each patient. In this article, we review the available literature attempting to delineate the role of genomic variations in clozapine and risperidone response in schizophrenic patients of various ethnicities. We conclude that pharmacogenomics for these two drugs is still not ready for implementation in the clinic.
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Affiliation(s)
- Evangelia Eirini Tsermpini
- University of Patras School of Health Sciences, Department of Pharmacy, University Campus, Rion, GR-26504, Patras, Greece
| | | | - Marina Bartsakoulia
- University of Patras School of Health Sciences, Department of Pharmacy, University Campus, Rion, GR-26504, Patras, Greece
| | - Gregoris Iconomou
- University of Patras School of Medicine, Department of Psychiatry, Rion, Patras, Greece
| | - Eleni Merkouri Papadima
- University of Patras School of Health Sciences, Department of Pharmacy, University Campus, Rion, GR-26504, Patras, Greece
| | | | - Alessio Squassina
- University of Cagliari, Department of Biomedical Sciences, Cagliari, Sardinia, Italy
| | - George P Patrinos
- University of Patras School of Health Sciences, Department of Pharmacy, University Campus, Rion, GR-26504, Patras, Greece
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Abstract
INTRODUCTION Clozapine, an atypical antipsychotic with documented efficacy in the management of treatment-resistant schizophrenia, is associated with the risk of adverse hematological outcomes. Of particular concern are reductions in white blood cells (WBC) and absolute neutrophil counts (ANC). Individuals who display moderate leukopenia (3000/mm(3) > WBC ≥ 2000/mm) upon initiation of clozapine therapy are at increased risk of developing agranulocytosis, defined as an ANC less than 500/mm. Complications of agranulocytosis can be severe and include increased risk of infection and mortality. OBJECTIVES The primary objective of this study was to examine data on clozapine recipients who experienced adverse drug reactions (ADRs) related to decreases in WBC or ANC and ascertain whether other drugs and/or drug interactions had played a role. The analysis included multiple classes of medications. METHODS A retrospective chart review was performed of open and closed medical records of all inpatient recipients of clozapine at a state psychiatric center between January 1, 2004 and June 30, 2011. Laboratory records of patients prescribed clozapine were examined for abnormal WBC counts or ANC. A hematological ADR was considered to have occurred if there was a substantial drop in either WBC or ANC or mild or moderate leukopenia or granulocytopenia. Each episode was analyzed for medications that might have contributed to the ADR. Data were collected for all scheduled and STAT medications started at any point during the clozapine patient's hospitalization. The following seven medication groups, based on the Therapeutic Classification System of the American Hospital Formulary System (AHFS), were chosen for analysis because they were consistently used in the majority of the patient population: antihistamines, anti-infectives, autonomic agents, cardiovascular agents, antipsychotics, vitamins, and gastrointestinal agents. Pearson correlation coefficients were calculated to identify associations between the presence of hematological ADRs and medications administered concomitantly with clozapine. RESULTS The following significant correlation coefficients were found between the use of a class of medications and the occurrence of a hematological ADR: antiinfective agents 0.409 (p < 0.01), gastrointestinal agents 0.329 (p < 0.01), and autonomic agents 0.309 (p < 0.01). In the subset of patients who were prescribed a proton-pump inhibitor or ranitidine concomitantly with clozapine, 24/26 (96%) experienced a hematological ADR. CONCLUSIONS Autonomic agents, anti-infective agents, and proton pump inhibitors and other gastrointestinal agents were all associated with hematological ADRs when co-prescribed with clozapine. Medications from these classes should be initiated cautiously in patients being treated with clozapine to avoid precipitous drops in ANC or WBC that may increase the risk of agranulocytosis.
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Abdelrahman Y, Fararjeh M, Abdel-Razeq W, Mohammad MK, Bustanji Y. Assessment of possible immunotoxicity of the antipsychotic drug clozapine. ACTA ACUST UNITED AC 2013; 66:378-86. [PMID: 24325666 DOI: 10.1111/jphp.12150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 08/25/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The immunomodulatory effects of clozapine (CLZ), antipsychotic drug, were investigated in vivo using female Balb/c mice. The main aim of this study was to evaluate the immunomodulatory effects of CLZ, antipsychotic drug, following daily intraperitoneal injection to female Balb/c mice over a period of 21 days. METHODS Mice were divided into five groups, eight animals per group. Group I, served as a control group, received only the vehicle. Groups II-V received a daily intraperitoneal dose of CLZ (1, 5, 10 and 20 mg/kg, respectively) over a period of 21 days. KEY FINDINGS CLZ has shown a significant decrease in the animal body weight, and it showed a significant decrease in the percentage of circulating neutrophils and lymphocytes while circulating monocytes were increased. The immunotoxicity has been also assessed by evaluating spleen cellularity, humoral immune response to a foreign antigen using sheep red blood cells and delayed-type hypersensitivity reaction. The results showed a marked suppression in these responses in CLZ-treated mice compared with the control group. Detectable changes have also been noticed in the histology of the footpad tissue and spleen. CONCLUSIONS Results showed significant immunomodulatory effects of CLZ when used in Balb/c mice.
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Affiliation(s)
- Yaseen Abdelrahman
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, The Hashemite University, Zarqa, Jordan
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Drug-induced agranulocytosis in the Berlin case–control surveillance study. Eur J Clin Pharmacol 2013; 70:339-45. [DOI: 10.1007/s00228-013-1618-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 11/20/2013] [Indexed: 12/18/2022]
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Massari NA, Medina VA, Cricco GP, Martinel Lamas DJ, Sambuco L, Pagotto R, Ventura C, Ciraolo PJ, Pignataro O, Bergoc RM, Rivera ES. Antitumor activity of histamine and clozapine in a mouse experimental model of human melanoma. J Dermatol Sci 2013; 72:252-62. [PMID: 23999004 DOI: 10.1016/j.jdermsci.2013.07.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND Functional presence of histamine H4 receptor (H4R) was demonstrated in human melanoma cell lines and biopsies. OBJECTIVE The purposes of this work were to investigate signal transduction pathways and biological responses triggered by the activation of H4R in human primary (WM35) and metastatic (M1/15) melanoma cell lines and to evaluate the in vivo antitumor activity of histamine (HA) and clozapine (CLZ) on human M1/15 melanoma xenografts. METHODS Clonogenic assay, incorporation of BrdU, cell cycle distribution, phosphorylation levels of ERK1/2 and cAMP production were evaluated in vitro. An experimental human melanoma model was developed into athymic nude mice. Tumor growth, survival and histochemical studies were performed in order to investigate the expression levels of H4R, HA, PCNA, mitotic index (MI), and angiogenesis. RESULTS The results indicate that H4R agonists inhibited forskolin-induced cAMP levels only in M1/15 cells while increased phosphorylation levels of ERK1/2 and decreased proliferation in both cell types. In vivo studies show that HA and CLZ (1mgkg(-1), sc) significantly increased median survival and decreased tumor volume. These effects were associated to a reduction in MI, in the expression of proliferation marker and in intratumoral neovascularization. CONCLUSIONS We conclude that HA and CLZ exhibit an antitumoral effect in vitro and in vivo on human melanoma, suggesting the therapeutic potential of these compounds for the treatment of malignant melanoma.
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Affiliation(s)
- Noelia A Massari
- Laboratory of Radioisotopes, School of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires 1113, Argentina
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Debnath M, Cannon DM, Venkatasubramanian G. Variation in the major histocompatibility complex [MHC] gene family in schizophrenia: associations and functional implications. Prog Neuropsychopharmacol Biol Psychiatry 2013; 42:49-62. [PMID: 22813842 DOI: 10.1016/j.pnpbp.2012.07.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/23/2012] [Accepted: 07/09/2012] [Indexed: 02/06/2023]
Abstract
Schizophrenia is a chronic debilitating neuropsychiatric disorder with a complex genetic contribution. Although multiple genetic, immunological and environmental factors are known to contribute to schizophrenia susceptibility, the underlying neurobiological mechanism(s) is yet to be established. The immune system dysfunction theory of schizophrenia is experiencing a period of renewal due to a growth in evidence implicating components of the immune system in brain function and human behavior. Current evidence indicates that certain immune molecules such as Major Histocompatibility Complex (MHC) and cytokines, the key regulators of immunity and inflammation are directly involved in the neurobiological processes related to neurodevelopment, neuronal plasticity, learning, memory and behavior. However, the strongest support in favor of the immune hypothesis has recently emerged from on-going genome wide association studies advocating MHC region variants as major determinants of one's risk for developing schizophrenia. Further identification of the interacting partners and receptors of MHC molecules in the brain and their role in down-stream signaling pathways of neurotransmission have implicated these molecules as potential schizophrenia risk factors. More recently, combined brain imaging and genetic studies have revealed a relationship between genetic variations within the MHC region and neuromorphometric changes during schizophrenia. Furthermore, MHC molecules play a significant role in the immune-infective and neurodevelopmental pathogenetic pathways, currently hypothesized to contribute to the pathophysiology of schizophrenia. Herein, we review the immunological, genetic and expression studies assessing the role of the MHC in conferring risk for developing schizophrenia, we summarize and discuss the possible mechanisms involved, making note of the challenges to, and future directions of, immunogenetic research in schizophrenia.
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Affiliation(s)
- Monojit Debnath
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore-560029, India.
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Tan ML, Basu D, Kwiecien JM, Johnson RL, Mishra RK. Preclinical pharmacokinetic and toxicological evaluation of MIF-1 peptidomimetic, PAOPA: examining the pharmacology of a selective dopamine D2 receptor allosteric modulator for the treatment of schizophrenia. Peptides 2013; 42:89-96. [PMID: 23416534 DOI: 10.1016/j.peptides.2013.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 11/28/2022]
Abstract
Schizophrenia is a mental illness characterized by a breakdown in cognition and emotion. Over the years, drug treatment for this disorder has mainly been compromised of orthosteric ligands that antagonize the active site of the dopamine D2 receptor. However, these drugs are limited in their use and often lead to the development of adverse movement and metabolic side effects. Allosteric modulators are an emerging class of therapeutics with significant advantages over orthosteric ligands, including an improved therapeutic and safety profile. This study investigates our newly developed allosteric modulator, PAOPA, which is a specific modulator of the dopamine D2 receptor. Previous studies have shown PAOPA to attenuate schizophrenia-like behavioral abnormalities in preclinical models. To advance this newly developed allosteric drug from the preclinical to clinical stage, this study examines the pharmacokinetic behavior and toxicological profile of PAOPA. Results from this study prove the effectiveness of PAOPA in reaching the implicated regions of the brain for therapeutic action, particularly the striatum. Pharmacokinetic parameters of PAOPA were found to be comparable to current market antipsychotic drugs. Necropsy and histopathological analyses showed no abnormalities in all examined organs. Acute and chronic treatment of PAOPA indicated no movement abnormalities commonly found with the use of current typical antipsychotic drugs. Moreover, acute and chronic PAOPA treatment revealed no hematological or metabolic abnormalities classically found with the use of atypical antipsychotic drugs. Findings from this study demonstrate a better safety profile of PAOPA, and necessitates the progression of this newly developed therapeutic for the treatment of schizophrenia.
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Affiliation(s)
- Mattea L Tan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
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[Essential tremor: update]. Med Clin (Barc) 2013; 140:128-33. [PMID: 22995841 DOI: 10.1016/j.medcli.2012.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/02/2012] [Accepted: 07/05/2012] [Indexed: 11/23/2022]
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Immunomodulatory effects of clozapine and their clinical implications: what have we learned so far? Schizophr Res 2012; 140:204-13. [PMID: 22831769 DOI: 10.1016/j.schres.2012.06.020] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 06/02/2012] [Accepted: 06/19/2012] [Indexed: 01/24/2023]
Abstract
Clozapine remains the drug of choice for treatment resistant schizophrenia, but is associated with potentially life threatening side effects, including agranulocytosis and myocarditis. Immunological mechanisms may be involved in the development of these side effects or in the unique antipsychotic efficacy in subgroups of schizophrenia patients. This systematic review presents the immunomodulatory effects of clozapine from human in vitro and in vivo studies and relates these findings to the developments of adverse and therapeutic effects of clozapine. Several studies confirm the immunomodulatory actions of clozapine, but only few studies investigated their relationship to the unique adverse and therapeutic effects of clozapine. During the first month of clozapine treatment, up to 50% of patients develop fever and flu like symptoms, which is seemingly driven by increased cytokines. Within the same time period, the risk of side-effects with a suspected immunological mechanism peaks. Patients developing fever during the first weeks of treatment should have a thorough physical examination, and measurements of white blood cell count, absolute neutrophil count, ECG, C-reactive protein, creatinine kinase, and troponin to exclude infection, agranulocytosis, myocarditis and neuroleptic malignant syndrome. To what degree the unique antipsychotic efficacy of clozapine in subgroups of schizophrenia patients is related to its immunomodulatory effects has not been studied. Research relating the immunomodulatory actions of clozapine and its early markers to clinically relevant adverse and therapeutic outcomes is hoped to provide new leads for the understanding of the pathophysiology of schizophrenia and aid the development of novel treatment targets.
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Abstract
There is substantial interindividual variability in the effects of treatment with antipsychotic drugs not only in the emergence of adverse effects but also in symptom response. It is becoming increasingly clear that much of this variability is due to genetic factors; pharmacogenetics is the study of those factors, with the eventual goal of identifying genetic predictors of treatment effects. There have been many reported associations of single nucleotide polymorphisms (SNPs) in candidate genes with the consequences of antipsychotic drug treatment. Thus variations in dopaminergic and serotoninergic genes may influence positive and negative symptom outcome, respectively. Among the adverse effects, tardive dyskinesia and weight gain have been the most studied, with some consistent associations of functional SNPs in genes relating to pharmacological mechanisms. Technological advance has permitted large-scale genome-wide association studies (GWAS), but as yet there are few reports that replicate prior findings with candidate genes. Nevertheless, GWAS may identify associations which provide new clues relating to underlying mechanisms.
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Affiliation(s)
- Gavin P Reynolds
- Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK.
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Chowdhury NI, Remington G, Kennedy JL. Genetics of antipsychotic-induced side effects and agranulocytosis. Curr Psychiatry Rep 2011; 13:156-65. [PMID: 21336863 DOI: 10.1007/s11920-011-0185-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Antipsychotic medication has been enormously helpful in the treatment of psychotic symptoms during the past several decades. Unfortunately, several important side effects that can cause significant morbidity and mortality. The two most common are abnormal involuntary movements (tardive dyskinesia) and weight gain progressing through diabetes to metabolic syndrome. A more rare and life-threatening adverse effect is clozapine-induced agranulocytosis (CIA), which has been linked to clozapine use. Clozapine itself has a unique position among antipsychotic medications, representing the treatment of choice in refractory schizophrenia. Unfortunately, the potential risk of agranulocytosis, albeit small, prevents the widespread use of clozapine. Very few genetic determinants have been clearly associated with CIA due to small sample sizes and lack of replication in subsequent studies. The HLA system has been the main hypothesized region of interest in the study of CIA, and several gene variants in this region have been implicated, particularly variants of the HLA-DQB1 locus. A preliminary genome-wide association study has been conducted on a small sample for CIA, and a signal from the HLA region was noted. However, efforts to identify key gene mechanisms that will be useful in predicting antipsychotic side effects in the clinical setting have not been fully successful, and further studies with larger sample sizes are required.
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Affiliation(s)
- Nabilah I Chowdhury
- Neurogenetics Section, Neuroscience Department, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T1R8, Canada
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Exploring off-targets and off-systems for adverse drug reactions via chemical-protein interactome--clozapine-induced agranulocytosis as a case study. PLoS Comput Biol 2011; 7:e1002016. [PMID: 21483481 PMCID: PMC3068927 DOI: 10.1371/journal.pcbi.1002016] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 01/25/2011] [Indexed: 12/20/2022] Open
Abstract
In the era of personalized medical practice, understanding the genetic basis of patient-specific adverse drug reaction (ADR) is a major challenge. Clozapine provides effective treatments for schizophrenia but its usage is limited because of life-threatening agranulocytosis. A recent high impact study showed the necessity of moving clozapine to a first line drug, thus identifying the biomarkers for drug-induced agranulocytosis has become important. Here we report a methodology termed as antithesis chemical-protein interactome (CPI), which utilizes the docking method to mimic the differences in the drug-protein interactions across a panel of human proteins. Using this method, we identified HSPA1A, a known susceptibility gene for CIA, to be the off-target of clozapine. Furthermore, the mRNA expression of HSPA1A-related genes (off-target associated systems) was also found to be differentially expressed in clozapine treated leukemia cell line. Apart from identifying the CIA causal genes we identified several novel candidate genes which could be responsible for agranulocytosis. Proteins related to reactive oxygen clearance system, such as oxidoreductases and glutathione metabolite enzymes, were significantly enriched in the antithesis CPI. This methodology conducted a multi-dimensional analysis of drugs' perturbation to the biological system, investigating both the off-targets and the associated off-systems to explore the molecular basis of an adverse event or the new uses for old drugs. Idiosyncratic drug reactions (IDR) generally cannot be identified until after a drug is taken by a large population, but usually result in restricted use or withdrawal. Clozapine provides the most effective treatment for schizophrenia but its use is limited because of a life-threatening IDR, i.e., the agranulocytosis. A high impact clinical study demonstrated the necessity of moving clozapine from 3rd line to 1st line drug; therefore, intensive research has aimed at identifying genes responsible for clozapine-induced agranulocytosis (CIA). Olanzapine, an analog of clozapine, has much lower incidence of agranulocytosis. Based on this phenomenon, we proposed an in silico methodology termed as antithesis chemical-protein interactome (CPI), which mimics the differences in the drug-protein interactions of the two drugs across a panel of human proteins. e.g., HSPA1A was identified to be targeted by clozapine not olanzapine. Furthermore, the gene expression of the HSPA1A-related gene system was also found up-regulated after clozapine treatment. This approach can examine the system's perturbation in terms of both the off-target and the off-system's interaction with the drug, providing theoretical basis for decoding the adverse drug reactions or the new uses for old drugs.
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Nooijen PMM, Carvalho F, Flanagan RJ. Haematological toxicity of clozapine and some other drugs used in psychiatry. Hum Psychopharmacol 2011; 26:112-9. [PMID: 21416507 DOI: 10.1002/hup.1181] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 01/19/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review recent work on the haematological toxicity of clozapine and some other drugs used in psychiatry concerning especially (i) the mechanism of antipsychotic-induced neutropenia/agranulocytosis, (ii) criteria for clozapine prescribing in benign ethnic neutropenia, (iii) options in the event of worrying falls in white cell count (WCC), including measures to boost WCC with or without continued clozapine administration, (iv) criteria for clozapine rechallenge in the event that treatment was suspended because of a fall in WCC and (v) safety concerns regarding clozapine in children/adolescents. CONCLUSIONS There remain several difficult areas, including the criteria for clozapine rechallenge. Experience has emphasised (i) the role of appropriate timing of WCC sample collection to ensure that clozapine is not withdrawn unnecessarily and (ii) the success of agents such as filgrastim in promoting rapid production of granulocytes if the situation so demands. On the other hand, the use of lithium to promote a leucocytosis has taken hold without a clear risk: benefit analysis. Be this as it may, should patients decide that they no longer wish to undergo WCC monitoring after 12 months on clozapine, cessation of monitoring is probably preferable to stopping the drug since overall mortality is decreased in patients treated with clozapine.
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Affiliation(s)
- Patty M M Nooijen
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
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Agid O, Foussias G, Singh S, Remington G. Where to position clozapine: re-examining the evidence. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2010; 55:677-84. [PMID: 20964947 DOI: 10.1177/070674371005501007] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review clozapine's position in treatment algorithms for schizophrenia. METHOD Clozapine's status is reviewed in the context of its initial discovery and unique clinical and (or) pharmacological profile, withdrawal and link with hematologic concerns, reintroduction with monitoring guidelines, prototype for atypicality, positioning in treatment algorithms, and current evidence regarding efficacy, effectiveness, and side effects. RESULTS The hematologic monitoring implemented with clozapine's reintroduction here in North America has proven successful in preventing clozapine-related deaths secondary to agranulocytosis. While its other side effects are not without concern, present evidence does not link clozapine to increased mortality rates; indeed, it appears better than other antipsychotics in this regard. Moreover, its clinical superiority compared with all other antipsychotics has been confirmed both in efficacy and in effectiveness trials. CONCLUSIONS Schizophrenia continues to represent a treatment challenge, with many people demonstrating suboptimal response and poor functional outcome. Clozapine is routinely positioned as a third-line treatment in schizophrenia, but in light of existing evidence this warrants re-examination.
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Affiliation(s)
- Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Ontario.
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Haile CN, Kosten TR. The potential of pharmacogenomics to treat drug addiction. Pharmacogenomics 2010; 10:1883-6. [PMID: 19958085 DOI: 10.2217/pgs.09.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wist AD, Berger SI, Iyengar R. Systems pharmacology and genome medicine: a future perspective. Genome Med 2009; 1:11. [PMID: 19348698 PMCID: PMC2651594 DOI: 10.1186/gm11] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Genome medicine uses genomic information in the diagnosis of disease and in prescribing treatment. This transdisciplinary field brings together knowledge on the relationships between genetics, pathophysiology and pharmacology. Systems pharmacology aims to understand the actions and adverse effects of drugs by considering targets in the context of the biological networks in which they exist. Genome medicine forms the base on which systems pharmacology can develop. Experimental and computational approaches enable systems pharmacology to obtain holistic, mechanistic information on disease networks and drug responses, and to identify new drug targets and specific drug combinations. Network analyses of interactions involved in pathophysiology and drug response across various scales of organization, from molecular to organismal, will allow the integration of the systems-level understanding of drug action with genome medicine. The interface of the two fields will enable drug discovery for personalized medicine. Here we provide a perspective on the questions and approaches that drive the development of these new interrelated fields.
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Affiliation(s)
- Aislyn D Wist
- Department of Pharmacology and Systems Therapeutics, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
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