Clozapine: why wait to start a laxative?

2019 ◽  
Vol 25 (6) ◽  
pp. 377-386
Author(s):  
Azizah Attard ◽  
Andrew Iles ◽  
Stephen Attard ◽  
Nathan Atkinson ◽  
Anita Patel
Keyword(s):  
Side Effects ◽  
Prophylactic Treatment ◽  
Toxic Megacolon ◽  
Learning Objectives ◽  
Regulatory Agencies ◽  
List Type ◽  
Treatment Resistant ◽  
Bowel Ischaemia ◽  
Life Threatening ◽  
Minor Side Effect

SUMMARYClozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.LEARNING OBJECTIVES:After reading this article you will be able to: •understand the mechanism of gastrointestinal hypomotility in those taking clozapine•improve the monitoring of clozapine-induced constipation•understand prophylactic laxative treatment and the use of less commonly prescribed laxatives in patients who experience clozapine-induced constipation.

scholarly journals Clozapine & constipation: an audit of bowel habit monitoring and laxative prescribing in inpatients on clozapine

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S67-S67
Author(s):  
Holly Boyd ◽  
Anna Manso de Zuniga
Keyword(s):  
Side Effects ◽  
Mortality Rate ◽  
Bowel Habit ◽  
Prescribing Practices ◽  
Pharmacy Records ◽  
Bowel Ischaemia ◽  
Bowel Habits ◽  
Current Medication ◽  
Life Threatening ◽  
Audit Standard

AimsTo establish how often bowel habits are monitored in inpatients on clozapineTo determine how many of these patients are prescribed laxatives and whether these are utilisedBackgroundIt's estimated that 30-60% of patients will suffer from constipation whilst on clozapine; this can lead to ileus, intestinal obstruction and bowel ischaemia, all of which can be fatal. Constipation is much more common than clozapine-induced blood dyscrasias, and has a higher mortality rate. Despite this, there is no strict universal framework for bowel habit monitoring equivalent to the compulsory FBC monitoring. Local trust guidance indicates that bowel habits should be monitored regularly, at least at any point of blood sampling. However, monitoring processes across the trust were noted to be variable, as were laxative prescribing practices.MethodThe data sample of current inpatients on clozapine across the trust was identified from pharmacy records. The patient's Rio notes from the preceding 3 months were searched for predetermined terms relating to bowel habits and constipation, and the notes were then analysed for assessment of bowel habit. The number of FBCs collected during this 3 month period was then used to produce comparison with the audit standard. The data on laxative prescribing were collected from current medication lists on EPMA.ResultA data sample of 31 current inpatients was identified. The audit found that only 54.8% (17) of patients had their bowel habits monitored at least with every FBC taken. There was significant variability between different wards, with the best performing ward having 100% adherence to the audit standard, and the worst performing having 0%. In terms of laxative prescribing, it was found that 87.1% (27) of patients had at least 1 regular or 1 PRN laxative prescribed. Regular laxatives were prescribed for 61.2% (19) of patients, whereas only PRN laxatives were prescribed in 25.8% (8) of patients. Of those prescribed only PRN laxatives, only 50% (4) ever utilised this medication.ConclusionBowel habits are not consistently monitored across the trust in inpatients on clozapine, leaving room for potentially life-threatening side effects to be missed. Additionally, regular laxative prescribing is not standard throughout the trust, which could further add to the potential for significant constipation-related morbidity to occur. A standard method of monitoring bowel habits throughout the trust, as well as a trust laxative prescribing policy, could be a way of remedying this issue and preventing harmful outcomes for our patients on clozapine.

Delirium on clozapine: A tale of friend turned foe-A case report

2020 ◽  
pp. 009121742097282 ◽  
Author(s):  
Aparna Das ◽  
Rebecca Minner ◽  
Lewis Krain ◽  
John Spollen
Keyword(s):  
Case Report ◽  
Clinical Practice ◽  
Side Effects ◽  
Adverse Effects ◽  
Older Adult ◽  
Psychiatric Illness ◽  
Management Strategies ◽  
Treatment Resistant ◽  
Drug Of Choice ◽  
Life Threatening

Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.

scholarly journals Clozapine use in old age psychiatry

2018 ◽  
Vol 24 (3) ◽  
pp. 204-211
Author(s):  
Amey Kirrane ◽  
Biswadeep Majumdar ◽  
Anna Richman
Keyword(s):  
Older Adults ◽  
Old Age ◽  
Older Patients ◽  
Learning Objectives ◽  
Ageing Population ◽  
List Type ◽  
Treatment Resistant ◽  
Working Age ◽  
Old Age Psychiatry ◽  
Effective Drugs

SUMMARYClozapine is one of the most effective drugs available to psychiatrists for treating psychosis. It is currently licensed for use in treatment-resistant schizophrenia and psychosis in Parkinson's disease, but its use in old age psychiatry is very uncommon. With the ageing population, and the increased incidence of psychosis in older patients, it is important to consider whether this is a drug that is not being used to its full advantage.LEARNING OBJECTIVES•Appreciate the differences in titration and monitoring of clozapine in older adults, compared with working-age adults•Consider the efficacy of clozapine in older people and its impact on mortality•Understand the side-effect profile of clozapine in older adultsDECLARATION OF INTERESTNone.

scholarly journals Hyponatraemia secondary to nivolumab-induced primary adrenal failure

2016 ◽  
Vol 2016 ◽  
Author(s):  
Harris Trainer ◽  
Paul Hulse ◽  
Claire E Higham ◽  
Peter Trainer ◽  
Paul Lorigan
Keyword(s):  
Side Effects ◽  
Malignant Melanoma ◽  
Checkpoint Inhibitors ◽  
Death Receptor ◽  
Serum Cortisol ◽  
List Type ◽  
Adrenal Failure ◽  
First Case ◽  
Advanced Malignant Melanoma ◽  
Life Threatening

Summary Checkpoint inhibitors, such as ipilimumab and pembrolizumab, have transformed the prognosis for patients with advanced malignant melanoma and squamous non-small-cell lung cancer, and their use will only expand as experience is gained in a variety of other malignancies, for instance, renal and lymphoma. As the use of checkpoint inhibitors increases, so too will the incidence of their unique side effects, termed immune-related adverse events (irAEs), which can affect dermatological, gastrointestinal, hepatic, endocrine and other systems. Nivolumab is a monoclonal antibody that blocks the human programmed death receptor-1 ligand (PD-L1) found on many cancer cells and is licensed for the treatment of advanced malignant melanoma. We describe the first case of nivolumab-induced adrenalitis resulting in primary adrenal failure presenting with hyponatraemia in a 43-year-old man with malignant melanoma. The case highlights the potentially life-threatening complications of checkpoint inhibitors and the need for patient education and awareness of irAEs among the wider clinical community because such side effects require prompt recognition and treatment. Learning points: Nivolumab can cause primary adrenal insufficiency. Not all cases of hyponatraemia in patients with malignancy are due to SIADH. Any patient on a checkpoint inhibitor becoming unwell should have serum cortisol urgently measured and if in doubt hydrocortisone therapy should be initiated. Although hyponatraemia can occur in patients with ACTH deficiency, the possibility of primary adrenal failure should also be considered and investigated by measurement of renin, aldosterone and ACTH. Patients receiving checkpoint inhibitors require education on the potential risks of hypocortisolaemia. PET imaging demonstrated bilateral increased activity consistent with an autoimmune adrenalitis.

scholarly journals Evaluation of Fetal Arrhythmias

2010 ◽  
Vol 4 (1) ◽  
pp. 51-57
Author(s):  
George M Graham
Keyword(s):  
Multidisciplinary Approach ◽  
Learning Objectives ◽  
List Type ◽  
Pulsed Doppler ◽  
Ultrasound Evaluation ◽  
Different Types ◽  
Life Threatening ◽  
Fetal Arrhythmia

Abstract Fetal arrhythmias are not uncommon. The diagnosis of a fetal arrhythmia is challenging and normally requires referral for a detailed fetal echocardiogram. The first step in the ultrasound evaluation should be distinguishing whether the arrhythmia is an irregular rhythm, a bradycardia, or a tachycardia. This can be done by evaluating the arrhythmia using simultaneous atrial and ventricular M-mode or pulsed Doppler. Although the majority of fetal arrhythmias are self-limited and benign, some are potentially life-threatening for the fetus and for these cases a multidisciplinary approach to treatment may be required. Learning Objectives Know the different types of fetal arrhythmias Understand how fetal arrhythmias are diagnosed Know which fetal arrhythmias require treatment

Understanding and managing cardiac side-effects of second-generation antipsychotics in the treatment of schizophrenia

2019 ◽  
Vol 26 (1) ◽  
pp. 26-40 ◽  
Author(s):  
Mark Sweeney ◽  
Eromona Whiskey ◽  
Rishi K. Patel ◽  
Derek K. Tracy ◽  
Sukhi S. Shergill ◽  
...  
Keyword(s):  
Side Effects ◽  
Second Generation ◽  
List Type ◽  
Cardiac Side Effects ◽  
The Past ◽  
Second Generation Antipsychotics ◽  
Evidence Based Treatments ◽  
Life Threatening ◽  
The Common

SUMMARYSecond-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.LEARNING OBJECTIVESAfter reading this article you will be able to: •understand the relative incidence of cardiotoxic side-effects of the various SGAs•perform preliminary investigations to diagnose the common cardiotoxic side-effects of SGAs•understand the treatments for these cardiac side-effects and the role of cardiologists involved the care of these patients.

Case report of treatment resistant schizophreniaresponding to high dose quetiapine following clozapine withdrawal due to neutropenia

2011 ◽  
Vol 26 (S2) ◽  
pp. 1359-1359
Author(s):  
P. Chandrappa ◽  
L. Ho
Keyword(s):  
Side Effects ◽  
Therapeutic Response ◽  
Significant Proportion ◽  
High Dose ◽  
Treatment Resistant ◽  
Maximum Daily Dose ◽  
Daily Dose ◽  
Life Threatening ◽  
Therapeutic Alternatives ◽  
Clozapine Withdrawal

IntroductionPatients suffering from treatment-resistant schizophrenia pose a difficult therapeutic challenge. Although Clozapine is a well-established treatment in such cases, there is a significant proportion of patients who have to discontinue Clozapine due to life-threatening side-effects, despite achieving good therapeutic response. There is very limited literature on the therapeutic alternatives to Clozapine in the treatment of resistant schizophrenia.ObjectiveTo report a case of resistant schizophrenia responding to high dose Quetiapine, following discontinuation of Clozapine due to neutropenia.Clinical details of the case: We are presenting a case of a forty-two year old female patient with treatment resistant schizophrenia who achieved remission following treatment with Clozapine, but had to discontinue treatment due to neutropenia, which occurred on two occasions. Clozapine discontinuation resulted in rapid and severe relapse in her condition and re-admission to hospital. Quetiapine was initiated as this stage, but only partial improvement was noted at the manufacturer's stated maximum daily dose of 800 mg/day. Since the drug was being well tolerated the dose was gradually further increased.ResultsThe dose of Quetiapine was eventually increased up to 1400 mg/day, which produced significant response and the patient was discharged from hospital. Quetiapine at this dose was well tolerated with minimal side effects.ConclusionThe above report indicates that high-dose Quetiapine is a viable alternative to Clozapine in treating refractory schizophrenia. The findings from this report support further investigation of this approach in the form of larger scale clinical trials.

Cutaneous Adverse Events of Immune Checkpoint Inhibitors: A Summarized Overview

2019 ◽  
Vol 14 (1) ◽  
pp. 14-20 ◽  
Author(s):  
Kerasia-Maria Plachouri ◽  
Eleftheria Vryzaki ◽  
Sophia Georgiou
Keyword(s):  
Side Effects ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Checkpoint Inhibitors ◽  
Skin Toxicity ◽  
Maculopapular Rash ◽  
Symptomatic Treatment ◽  
Stevens Johnson Syndrome ◽  
Life Threatening ◽  
Skin Side Effects

Background:The introduction of Immune Checkpoint Inhibitors in the recent years has resulted in high response rates and extended survival in patients with metastatic/advanced malignancies. Their mechanism of action is the indirect activation of cytotoxic T-cells through the blockade of inhibitory receptors of immunomodulatory pathways, such as cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein-1 (PD-1) and its ligand (PD-L1). Despite their impressive therapeutic results, they can also induce immune-related toxicity, affecting various organs, including the skin.Objective:To provide an updated summarized overview of the most common immune-mediated cutaneous side effects and their management.Method:English articles derived from the databases PubMed and SCOPUS and published between 2009 and 2018, were analyzed for this narrative review.Results:The most common adverse cutaneous reactions include maculopapular rash, lichenoid reactions, vitiligo and pruritus, with severity Grade 1 or 2. Less frequent but eventually life-threatening skin side effects, including Stevens-Johnson syndrome, Drug Reaction with Eosinophilia and Systemic Symptoms and Toxic Epidermal necrolysis, have also been reported.Conclusion:Basic knowledge of the Immune-Checkpoint-Inhibitors-induced skin toxicity is necessary in order to recognize these treatment-related complications. The most frequent skin side effects, such as maculopapular rash, vitiligo and pruritus, tend to subside under symptomatic treatment so that permanent discontinuation of therapy is not commonly necessary. In the case of life-threatening side effects, apart from the necessary symptomatic treatment, the immunotherapy should be permanently stopped. Information concerning the management of ICIs-mediated skin toxicity can be obtained from the literature as well as from the Summary of Product Characteristics of each agent.

scholarly journals Experience with protein A-immunoadsorption in treatment-resistant adult immune thrombocytopenic purpura

Blood ◽  
1992 ◽  
Vol 79 (9) ◽  
pp. 2237-2245 ◽  
Author(s):  
HW Snyder ◽  
SK Cochran ◽  
JP Balint ◽  
JH Bertram ◽  
A Mittelman ◽  
...  
Keyword(s):  
Side Effects ◽  
Immune Thrombocytopenic Purpura ◽  
Protein A ◽  
Staphylococcal Protein A ◽  
Treatment Resistant ◽  
Thrombocytopenic Purpura ◽  
Specific Serum ◽  
Clinical Responses ◽  
Acute Increase

Abstract Extracorporeal immunoadsorption of plasma to remove IgG and circulating immune complexes (CIC) was evaluated as a therapy for adults with treatment-resistant immune thrombocytopenic purpura (ITP). Seventy-two patients with initial platelet counts less than 50,000/microL who had failed at least two other therapies were studied. They received an average of six treatments of 0.25 to 2.0 L plasma per procedure over a 2- to 3-week period using columns of staphylococcal protein A-silica (PROSORBA immunoadsorption treatment columns; IMRE Corp, Seattle, WA). The treatments caused an acute increase in the platelet count to greater than 100,000/microL in 18 patients and to 50,000 to 100,000/microL in 15 patients. The median time to response was 2 weeks. Responses were transient (less than 1 month duration) in seven of those patients (10%), but no additional relapses were reported over a follow- up period of up to 26 months (mean of 8 months). Clinical responses were associated with significant decreases in specific serum platelet autoantibodies (including anti-glycoprotein IIb/IIIa), platelet- associated Ig, and CIC. Thirty percent of treatments were associated with transient mild to moderate side effects usually presenting as a hypersensitivity-type reaction. Continued administration of failed therapies for ITP, which always included low-dose corticosteroids (less than or equal to 30 mg/d), had no demonstrable influence on the effectiveness of immunoadsorption treatment but did depress the incidence and severity of side effects. The degree of effectiveness of protein A immunoadsorption therapy in patients with treatment-resistant ITP is promising and further controlled studies in this patient population are warranted.

Proton Pump Inhibitors in 2021: Pros, Cons, and Everything in Between

2021 ◽  
pp. 263451612110217
Author(s):  
Joshua A. Sloan ◽  
Philip O. Katz
Keyword(s):  
Quality Of Life ◽  
Side Effects ◽  
Adverse Events ◽  
Proton Pump Inhibitors ◽  
Proton Pump ◽  
Drug Class ◽  
Life Threatening

The medical and lay literature has exploded with reports of adverse events associated with proton pump inhibitors over the last 10 to 15 years. The dissemination of these reports to patients and clinicians have created substantial concerns regarding what has been an exceptionally valuable drug class, dramatically improving patient quality of life, and in many cases preventing life threatening side effects of other medication. Patients are more frequently seeking to avoid these medications, and practitioners are reducing or discontinuing them to the patient’s detriment due to a misunderstanding of the data. This review will discuss the data regarding the most commonly publicized adverse events and attempt to put them in perspective.

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