It is possible to change clozapine by another neuroleptic

It is well known that when we have a schizophrenic patient who do not respond to two batches of neuroleptics at full dosage for more than six month, it may be wise to try with clozpine which is believed to be one of the best neuroleptics we have but with two main handicaps: it can produce leucopenia which can be fatal and epileptic seizures as well. We do think that in many cases, clozapine has been used too soon in the treatment of the schizophrenic patient, before we can really talk of a resistant patient. To prove that we have changed the clozapine treatment of four chronically ill schizophrenic patients admitted to a home for the chronically mentally ill. Two patients were changed from clozapine 400 mg/day to paliperidone 15 mg/day along two months time. They both improved in mental clarity and ability of thinking. Another patient were changed from 600 mg/day to 27 mg/day of paliperidone. That patient worsened a little bit mainly with hostility and social avoidance but it was mandatory to change neuroleptic because he had had two seizures and had low levels of platelets and therefore he was at risk of developing leukopenia. The fourth one was taking 300 mg of clozapine and was changed to 12 mg of paliperidone. We got no change in the clinical outcome.DiscussionWe discuss the different explanations for the results we got.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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A case of rare allele T 126, 30,32 base pairs in a schizophrenic patient: A study case

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2173 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S585-S586

Author(s):

A.I. Sabau ◽

P. Cristina ◽

B. Valerica ◽

P. Delia Marina

Keyword(s):

Schizophrenic Patient ◽

Complex Disease ◽

Susceptibility Gene ◽

Rflp Analysis ◽

Rare Allele ◽

Base Pairs ◽

Gene Coding ◽

Icd 10 ◽

Schizophrenic Patients ◽

Competing Interest

IntroductionSchizophrenia is a severe and complex disease clinically characterized by disturbed thought processes, delusions, hallucinations and reduced social skills. Gene coding for neregulin 1 (NRG 1) located in 8 p21chromosomeand single nucleotide polymorphism (SNPs) have been identified strongly supporting NRG1 gene as a susceptibility gene for schizophrenia.ObjectiveThe present preliminary study, determines the relationship between polymorphism nucleotide sites (SNPs2) of NRG1 gene and schizophrenia.AimsIdentifying rare allele T of neregulin 1 genein schizophrenic patients.MethodWe analyzed the polymorphism (SNPs2) of NRG1 gene in 20 patients recruited from Psychiatry Department of Emergency Clinical Hospital of Arad diagnosed with schizophrenia according to DSM-5-TM and ICD-10 criteria and 10 healthy controls. From all subjects, we obtained 2 mL of peripheral blood samples. Genomic DNA was extracted using the phenol-chloroform method. Genotyping was performed byPCR-based RFLP analysis for all subjects. The obtained PCR product mixture was completely digested with restriction enzyme, separated on SNP1 and SNP2 agarose gel. We present the case of a 31 years old, male, schizophrenic patient with the SNPs2 polymorphism and rare allele T 126.ResultsIn both groups, common allele G 127 and 60 base pairs was identified but only 2 schizophrenic patients presented rare allele T 126 and 30,32 base pairs.ConclusionsThe polymorphism SNPs2 of NRG1 gene with rare allele T 126 and 30,32 base pairs, may play a role in predisposing an individual to schizophrenia. Further and extended replicating studies with multiple sequencing of NRG1 gene are necessary.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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The acting out in patients with Schizophrenia examined in a forensic psychiatric assessment

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.906 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S591-S591

Author(s):

S. Khouadja ◽

S. Younes ◽

S. Chatti ◽

R. Ben Soussia ◽

L. Zarrouk ◽

...

Keyword(s):

Risk Factors ◽

Mentally Ill ◽

University Hospital ◽

Acting Out ◽

Psychiatric Assessment ◽

Schizophrenic Patients ◽

Forensic Psychiatric ◽

Competing Interest ◽

Psychiatric Department ◽

Forensic Psychiatric Assessment

IntroductionMany studies have shown that schizophrenic patients are responsible for the highest rates of violence among all the mentally ill patients.Aims of the studyDescribe the socio-demographic and clinical characteristics of patients with schizophrenia examined in a forensic psychiatric assessment and identify the risk factors of violence in these patients.MethodologyA retrospective study carried out in the psychiatric department of university hospital of Mahdia during fifteen years involving 40 patients with schizophrenia examined in a forensic psychiatric assessment following a forensic act. These patients were compared to a population of 40 patients followed in the same establishment for the same disease and without criminal record.ResultsAge average of 36.08 years, male (95%), rural origin (65%), primary level education (47.5%), single (65%), unemployed (65%) and average socio-economic level (65%). Personal psychiatric history (87.5%), personality disorder (12.5%), judiciary history (12.5%) and substance abuse (57.5%). Subtypes of schizophrenia: undifferentiated (52.5%) and paranoid (30%). They have committed serious physical assaults (55%) and aggression against property (27.5%). The victim was mostly a family member (40%), under the influence of toxic (22%), driven by delusions of persecution (61%), with hallucinatory mechanism (55%). The psychiatric expert has concluded an abolition of discernment in 77.5% of cases. Risk factors of acting out were: rural origin, alcohol and psychoactive substances use, productive forms of schizophrenia, poor adherence and irregular monitoring.ConclusionThe knowledge of risk factors improves the management and allows us better prevention of violence among our patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Predictive biomarkers in clozapine-treated patients: Assessment of the evidences and suggestion for research methodology

European Psychiatry ◽

10.1016/j.eurpsy.2017.02.403 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S378-S378 ◽

Cited By ~ 1

Author(s):

F. Cerrato ◽

L. Guizzaro ◽

P. Scudellari ◽

A.R. Atti ◽

D. De Ronchi

Keyword(s):

Weight Gain ◽

Genetic Variants ◽

Association Studies ◽

Predictive Biomarkers ◽

Prognostic Biomarkers ◽

Clozapine Treatment ◽

Pubmed Database ◽

Schizophrenic Patients ◽

Competing Interest ◽

Positive Results

IntroductionPredictive biomarkers are tools that identify a subpopulation of patients who are most likely to respond to a given therapy. In order to identify them a strict methodology is necessary (RCT's studies). In consideration of its cost in economic and medical terms, predictive biomarkers would be useful to distinguish clozapine-resistant patients before its administration.AimsThe evidence concerning genetic biomarkers was reviewed with the aim of assessing whether there is enough evidence to claim for predictive biomarkers useful in practice. Secondary aims were the assessment of the evidence concerning genetic prognostic biomarkers and predictors of side effects in clozapine-treated schizophrenic patients.MethodsOne hundred and twenty-eight studies, searched on the Pubmed database or referenced in other studies, were included in this review. Sixty-five papers were related to clozapine efficacy and explored 167 genetic variants.ResultsFifty-four variants were supported as prognostic biomarkers, three were successfully replicated: rs6280, rs6314 and rs4680; 49 papers were related to clozapine weight gain and explored 216 different genetic variants. Forty-five of which were positively related to weight gain during clozapine treatment. Among these 45 variants, only two, Rs3813929 and Rs779039, were successfully replicated.Fourteen studies explored 111 genetic variants potentially correlated to Clozapine-induced agranulocytosis. Thirty-four variants were found to be associated with agranulocytosis. Five variants had positive results, successfully replicated. In particular, HLA B38.ConclusionsTo date there is no evidence to support a modification of clinical practice towards predictive medicine. The research could ideally progress with RCTs involving the prognostic factors found in association studies.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Polydipsia and intermittent hyponatremia

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.632 ◽

2017 ◽

Vol 41 (S1) ◽

pp. s502-s502

Author(s):

S. Ramos-Perdigues ◽

M.J. Gordillo ◽

C. Caballero ◽

S. Latorre ◽

S.V. Boned ◽

...

Keyword(s):

Mentally Ill ◽

Rare Condition ◽

Psychotropic Medications ◽

Auditory Hallucinations ◽

Psychiatric Ward ◽

Water Restriction ◽

Hippocampal Dysfunction ◽

Schizophrenic Patients ◽

Competing Interest ◽

Dilutional Hyponatraemia

IntroductionHyponatraemia occurs in 4% of schizophrenic patients. Dilutional hyponatraemia, due to inappropriate retention of water and excretion of sodium, occurs with different psychotropic medications and could lead to hippocampal dysfunction. This complication is usually asymptomatic but can cause severe problems, as lethargy and confusion, difficult to diagnose in mentally ill patients.ObjectivesTo describe a case of a patient with psychotropic poli-therapy, admitted three times due to hyponatremia and the pharmacological changes that improved his condition.AimsTo broadcast the intermittent hyponatraemia and polydipsia (PIP), a not rare condition, suffered by treated schizophrenic patients and discuss its physiopathology and treatment thorough a case report.MethodsA 56-year schizophrenic male was admitted for presenting disorganized behavior, agitation, auditory hallucinations, disorientation, ataxia, vomits and urinary retention. He was on clomipramine, haloperidol and clotiapine (recently added), quetiapine, fluphenazine and clonazepam. After water restriction his symptoms improved and he was discharged. Twenty-five days later, he was readmitted for presenting the same symptoms and after water restriction, he was discharged. Five days later, he was again admitted and transferred to the psychiatric ward.ResultsHaloperidol, fluphenazine and clomipramine were replaced by clozapine. These changes lead him to normalize the hypoosmolality and reduce his water-voracity. Endocrinology team did not label this episode of SIADH due to its borderline blood and urine parameters.ConclusionsHyponatremia is frequent in schizophrenic patients and may have severe consequences. Therefore, a prompt recognition and treatment is warranted.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Pro-BNP as a biomarker of asymptomatic clozapine-related heart dysfunction: Possible usefulness for clozapine management

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2029 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S549-S550 ◽

Cited By ~ 1

Author(s):

V. Prisco ◽

M. Petrosino ◽

M. Fabrazzo

Keyword(s):

Cardiac Dysfunction ◽

Adverse Reactions ◽

Cardiac Toxicity ◽

Beta Blockers ◽

Drug Resistant ◽

Intermittent Fever ◽

Clozapine Treatment ◽

Schizophrenic Patients ◽

Life Threatening ◽

Competing Interest

Cardiovascular clozapine-related side effects such as tachycardia and orthostatic hypotension are well recognized, but are rarely clinically important. However, the increasing number of life-threatening drug-related complications are giving rise to concerns about cardiac adverse reactions (myocarditis, cardiomyopathy, pericarditis and heart failure). The diagnosis is usually made considering patient's symptoms, such as tachycardia, slightly increased body temperature, subjective chest pain, dyspnea. However, this symptomatology is not always present in a clozapine-related pericarditis. Some authors suggest measuring BNP levels to detect early and asymptomatic cardiac dysfunction. We here report the clinical cases of two women, respectively 22 and 28 years old. They both suffered from an early onset resistant schizophrenia. Clozapine was gradually introduced, at a dose of 200 mg/day, in both patients. After about one month in both cases, while the first patient was nearly asymptomatic, apart from the intermittent fever (only PCR and pro-BNP values were elevated, 16.88 mg/dL and 1004 pg/mL, respectively), the second one showed a classic symptomatology suggestive of pericarditis. Clozapine was discontinued in both patients, resulting in progressive resolution of pericarditis. Interestingly, in the patient in which pro-BNP was elevated, after clozapine cessation, the pro-BNP fell down dramatically. Pro-BNP plasma levels appears to be an interesting test in identifying subjects with asymptomatic cardiac impairment. It would be useful to evaluate if early treatment with beta-blockers and ACE-inhibitors may allow the prosecution of clozapine treatment after developing of mild signs of cardiac toxicity in drug resistant schizophrenic patients responsive to clozapine.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Parkinson disease psychosis – A case report

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.258 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S147-S147

Author(s):

M.D.C. Ferreira ◽

S. Varanda ◽

G. Carneiro ◽

B. Santos ◽

Á. Machado

Keyword(s):

Impulse Control ◽

Disease Duration ◽

Motor Symptoms ◽

Agonist Therapy ◽

Clozapine Treatment ◽

Dopamine Agonist Therapy ◽

Severe Motor ◽

History Of ◽

Competing Interest ◽

Motor Effects

IntroductionPsychosis is one of the most prevalent non-motor complications in Parkinson's disease (PD). Risk factors for PD psychosis are advancing age, longer disease duration, severe motor symptoms, presence of dementia, sleep disorders, depression and autonomic dysfunction. Treatment is challenging in this setting because antipsychotic medications are known to worse motor symptoms.ObjectivesTo highlight the therapeutic difficulties in PD-related psychosis.MethodsCase description and literature review.ResultsWe report a case of a 74-year-old woman with a 9-year history of PD, who presented a complex psychotic disorder consisting in auditory, olfactory and visual (gulliverian and lilliputian) hallucinations, persecutory and sexual delusions. Additionally, the patient presented euthymic mood, without evidence of cognitive impairment or impulse-control disorder. These symptoms began after dopamine agonist therapy (ropinirole 4 mg/day). Other medical conditions that could justify these symptoms were excluded. Initially, ropinirole was removed, but without psychotic remission. Then, she was treated with antipsychotic medication (clozapine 25 mg/day) with full psychotic remission and without significant worsening of motor symptoms.ConclusionsClozapine treatment is frequently delayed, mainly for fear of its side effects, particularly agranulocytosis. However, this antipsychotic drug presents many benefits regarding the management of PD-related psychosis, namely few motor effects and even improvement of motor fluctuations.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Insight and aggressive Behavior in acute Schizophrenic Patients

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1602 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S441-S441

Author(s):

S. Campi ◽

C. Esposito ◽

P. andreassi ◽

P. Bandinelli ◽

P. Girardi ◽

...

Keyword(s):

Aggressive Behavior ◽

Treatment Compliance ◽

Aggressive Behaviors ◽

Self Monitoring ◽

Poor Treatment ◽

Schizophrenic Patients ◽

Competing Interest ◽

The Relationship ◽

Acute Patients

Introductionaggressive behavior in wards is associated to poor treatment compliance and low clinical insight. Most studies focused on the clinical and cognitive dimensions of insight, while the relationship between metacognitive dimension and aggressive behaviors was not investigated. Our aim was to understand what relationship occurs between dimensions of insight (metacognitive, cognitive, clinical), and specific aggressive behaviors in acute patients.Methodswe recruited 75 acute schizophrenic patients using: aQ; MO aS; IS; P aNSS; BCIS.Resultsa positive correlation between the IS score and the hostility, angry and physical aggression sub-scores of the aQ was highlighted, while no correlation between the score of IS and MO aS total score was found. No correlation between the score of the P aNSS G12 item and the aQ scores and MO aS was found, and no correlation between BCIS scores, MO aS and aQ scores was found.Conclusionsin our patients, a higher level of metacognitive insight, but not clinical nor cognitive insight, was associated to higher levels of hostility. we suggest that a higher ability to monitor and appraise one's own altered processes of thought and related discomfort, feeling of destabilization and loss of control, could contribute to enhance resentment and suspiciousness. Findings help develop specific therapeutic strategies to enhance metacognitive and self-monitoring abilities, helping patient's understanding of the illness, improving compliance with treatment, and patient's quality of life. Our results support the multidimensional nature of insight in schizophrenia, confirming that clinical, cognitive and metacognitive dimensions are independent though related facets of the phenomenon of insight in schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Side Effects of Clozapine and Their Relationship with Clinical Variables in Patients with Schizophrenia

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.2139 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S197-S197

Author(s):

G. Gürcan ◽

Ş. Hun Şenol ◽

A.E. Anıl Yağcıoğlu ◽

A. Ertuğrul

Keyword(s):

Metabolic Syndrome ◽

Side Effects ◽

Plasma Levels ◽

Rating Scale ◽

Clinical Status ◽

Clinical Variables ◽

Clozapine Treatment ◽

Clozapine Dose ◽

Severity Of Disability ◽

Competing Interest

IntroductionThe side effects of clozapine may affect the treatment process negatively, and increase the disability.AimsWe aimed to assess the side effects of clozapine, and their relationship with the clinical variables in schizophrenia patients, and study the predictors of disability.MethodsConsecutive 122 outpatients who met DSM-IV criteria for schizophrenia, and were on clozapine treatment were included in the study. Information about sociodemographic characteristics, past and current clinical status were gathered through a clinical interview and review of the medical records, and physical measures and laboratory tests, including clozapine plasma levels, were recorded. The patients were assessed with SCID-I, Positive and Negative Syndrome Scale, UKU-Side Effect Rating Scale, WHO-Disability Assessment Schedule-II.ResultsHypersalivation, weight gain, sedation and constipation were the most common side effects of clozapine. Although the mean plasma clozapine levels were high (828.11 ± 445.5 ng/mL), no significant effect of clozapine dose and plasma levels were detected on the severity of side effects, except for constipation. Metabolic syndrome prevalence was found to be 50% according to ATP IIIA criteria. Duration of clozapine treatment, clozapine dose and plasma levels were not significantly different between patients with and without metabolic syndrome. Regression analysis showed that the severity of schizophrenia psychopathology and the number of side effects predicted the severity of disability.ConclusionsSide effects of clozapine increase the disability of patients with schizophrenia and should be monitored regularly. On the other hand, clozapine dose and plasma levels do not determine the severity of most of the common side effects.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Blonanserin augmentation in patients with schizophrenia – who is benefited from blonanserin augmentation?: An open-label, prospective, multicenter study

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.558 ◽

2016 ◽

Vol 33 (S1) ◽

pp. s226-s226

Author(s):

Y.S. Woo ◽

J.E. Park ◽

D.H. Kim ◽

I.K. Sohn ◽

T.Y. Hwang ◽

...

Keyword(s):

Multicenter Study ◽

Atypical Antipsychotics ◽

Therapeutic Strategy ◽

Psychiatric Symptoms ◽

Open Label ◽

Prospective Multicenter Study ◽

Syndrome Scale ◽

Schizophrenic Patients ◽

Competing Interest ◽

Negative Syndrome

IntroductionEvidences for antipsychotics augmentation for schizophrenic patients with suboptimal efficacy have been lacking although it has been widespread therapeutic strategy in clinical practice.ObjectivesThe purpose of this study was to investigate the efficacy and tolerability of blonanserin augmentation with an atypical antipsychotics (AAPs) in schizophrenic patients.MethodsA total of 100 patients with schizophrenia partially or completely unresponsive to treatment with an AAP recruited in this 12-week, open-label, non-comparative, multicenter study. Blonanserin was added to existing AAPs which were maintained during the study period. Efficacy was primarily evaluated using Positive and Negative Syndrome Scale (PANSS) at baseline, week 2, 4, 8, and 12. Predictors for PANSS response (≥ 20% reduction) was investigated.ResultsThe PANSS total score was significantly decreased at 12 weeks after blonanserin augmentation (–21.0 ± 18.1, F = 105.849, P < 0.001). Response rate on PANSS at week 12 was 51.0%. Premature discontinuation was occurred in 17 patients (17.0%) and 4 patients among them discontinued the study due to adverse events. Nine patients experienced significant weight gain during the study. Response to blonanserin augmentation was associated with severe (PANSS > 85) baseline symptom (OR = 10.298, P = 0.007) and higher dose (> 600 mg/day of chlorpromazine equivalent dose) of existing AAPs (OR = 4.594, P = 0.014).ConclusionsBlonanserin augmentation improved psychiatric symptoms of schizophrenic patients in cases of partial or non-responsive to an AAP treatment with favorable tolerability. Patients with severe symptom despite treatment with higher dose of AAP were benefited from this augmentation. These results suggested that blonanserin augmentation could be an effective strategy for specific patients with schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Electroconvulsive therapy in schizophrenia – where do we stand?

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.671 ◽

2016 ◽

Vol 33 (S1) ◽

pp. s262-s263

Author(s):

J. Silva ◽

J. Mota ◽

P. Azevedo

Keyword(s):

Side Effects ◽

Electroconvulsive Therapy ◽

Severe Depression ◽

Psychotic Symptoms ◽

Drug Intolerance ◽

Rapid Control ◽

Practice Of Medicine ◽

Nice Guidance ◽

Schizophrenic Patients ◽

Competing Interest

IntroductionElectroconvulsive therapy is currently used in the management of severe depression, long-term mania and catatonia. Regarding schizophrenia-related psychosis ECT is also an option, but the indication is restrictive to severe cases, drug intolerance or resistant ones. Lack of evidence of cost-effectiveness compared to clozapine, and side effects of ECT techniques before 2003, influenced NICE guidance to not recommend ECT in schizophrenia, but modern ECT machines and procedures are subsequent to 2003. ECT is often performed when clozapine fails to respond in monotherapy or if there is intolerance to antipsychotic side effects. ECT in combination with clozapine seems to have significant results allowing the patients to achieve rapid control of psychotic symptoms with fewer side effects, comparing with antipsychotics-association strategies.ObjectivesTo summarized the latest literature about this field and to present recent data from the Electrovulsivetherapy Unit, in Hospital de Magalhães Lemos, Portugal.AimTo explore and critically review the controversies of electroconvulsive therapy in the management of drug-resistant schizophrenia.MethodsRetrospective data of an Electroconvulsive Therapy Unit during 2006–2015 was review.Results198 ECT treatments in schizophrenic patients were performed in our unit, during 2006–2007, in a total of 647 ECT (30,6%). In 2014–2015, 945 schizophrenic patients received ECT treatment, in a total of 2149 performed ECT (43,9%).ConclusionsAlthough guidelines are crucial for the uniform practice of medicine, sometimes is important to be critical about them. The use of ECT in schizophrenia is safe and effective and further research is needed to continue to support this treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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