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PubMed2025

The time has come for revising the rules of clozapine blood monitoring in Europe. A joint expert statement from the European Clozapine Task Force.

The European Clozapine Task Force is a group of psychiatrists and pharmacologists practicing in 18 countries under European Medicines Agency (EMA) regulation, who are deeply concerned about the underuse of clozapine in European countries. Although clozapine is the most effective antipsychotic for people with treatment-resistant schizophrenia, a large proportion of them do not have access to this treatment. Concerns about clozapine-induced agranulocytosis and stringent blood monitoring rules are major barriers to clozapine prescribing and use. There is a growing body of evidence that the incidence of clozapine-induced agranulocytosis is very low after the first year of treatment. Maintaining lifelong monthly blood monitoring after this period contributes to unjustified discontinuation of clozapine. We leverage recent and replicated evidence on the long-term safety of clozapine to call for the revision and updating of the EMA's blood monitoring rules, thus aiming to overcome this major barrier to clozapine prescribing and use. We believe the time has come for relaxing the rules without increasing the risks for people using clozapine in Europe.

Clozapine↗

PubMed1978

Clozapine concentrations in brain regions: relationship to dopamine metabolite increase.

Levels of clozapine in rat striatum and tuberculum olfactorium were quantitated by a gas chromatographic technique. The relationship of the increase in 3,4-dihydroxyphenylacetic acid (DOPAC) in these regions produced by clozapine to the concentration of clozapine was explored. One hour after 10, 20 or 40 mg/kg clozapine i.p. the concentration of drug increased in proportion to the dose and at each dose was similar in striatum and T.O. The percent increase in DOPAC in both areas was related to the clozapine concentration in a typical dose--response manner and was greater in the striatum than the T.O. A relatively high concentration of clozapine (40 micron) was required to produce a half-maximal elevation of DOPAC. Striatal clozapine levels were similar in acutely and chronically treated animals. The concentrations of clozapine in striatum and T.O. reflect the dose injected and do not account for its atypical properties.

3,4-Dihydroxyphenylacetic Acid↗

PubMed1979

Effects of clozapine on the activity of central dopaminergic and noradrenergic neurons.

The effects of clozapine on the spontaneous firing rate of noradrenergic (NE, locus coeruleus), dopaminergic (DA, zona compacta, ventral tegmental area) and non-dopaminergic (zona reticulata) neurons was studied in chloral hydrate anesthetized rats. Clozapine administered intraperitoneally significantly increased the spontaneous activity of NE and DA neurons. After a cumulative dose of 8 mg/kg clozapine, the increase of mean firing rate per min of zona compacta and ventral tegmental area neurons attained almost similar values. Amphetamine reversed the clozapine-induced stimulation of NE and DA neurons. Zona reticulata neurons were depressed by clozapine. Neither amphetamine nor physostigmine were effective in antagonizing the inhibition. Our results suggest that clozapine blocks central NE and DA receptors. Furthermore, they fail to reveal a smaller sensitivity of the striatum as compared to the limbic system to the effects of clozapine.

Amphetamine↗

PubMed1976

In vivo actions of clozapine and haloperidol on the turnover rate of acetylcholine in rat striatum.

We have measured acetylcholine (ACh) content and turnover rate (TRACh) in striatum and cortex of rats receiving haloperidol and clozapine i.p. Both clozapine (30 mumol/kg) and haloperidol (10 mumol/kg) reverse the decrease in striatal TRACh elicited by apomorphine (11 mumol/kg) while each antipsychotic affects the steady state and the TRACh in striatum differently. Haloperidol fails to change striatal ACh content but increases the TRACh; chozapine (15 and 30 mumol/kg) neither decreases the content of ACh nor changes the TRACh in striatum. Moreover, 60 or 90 mumol/kg of clozapine causes a 40% decrease in ACh content without affecting the TRACh. Clozapine, but not haloperidol, antagonizes the increase in ACh content and the decrease in TRACh elicited by arecoline (64 mumol/kg) and oxotremorine (9 mumol/kg) in striatum. Clozapine resembles trihexylphenidyl (14 mumol/kg) and benztropine (12 mumol/kg) because it decreases the ACh content of striatum without changing the TRACh. Moreover, clozapine and benztropine reverse the increase in striatal TRACh elicited by haloperidol. The increase in striatal TRACh elicited by haloperidol could be of value to explain the extrapyramidal action of this drug. The anticholinergic action of clozapine could explain the absence of extrapyramidal side effects observed with this drug.

Animals↗

PubMed1978

A psychophysiological investigation of the long-term effects of clozapine upon sleep patterns of normal young adults.

A 25-night single-blind cross over design was employed to determine the long-term effects of clozapine on the sleep patterns of six normal young adults. Subjects received 12.50 mg placebo on the first and last five nights, whereas on the intermediate 15 nights 12.5 mg clozapine was administered. The subjects slept in the laboratory on the third and fourth nights to obtain baseline recordings, and on the eight, twelfth, sixteenth, and twentieth nights to determine the effects of clozapine on sleep variables. Recordings on nights 21 and 25 were used to assess withdrawal effects. Percentage stage 1 sleep and indices of body movements during sleep were significantly reduced, suggesting that clozapine may have sleep-inducing properties. There were no significant rebound of stage REM sleep during drug withdrawal despite a small but significant reduction in stage REM during drug administration. Numerous side effects, indicative of sleepiness, were reported on the mornings following drug administration, and there was evidence of a rapid tolerance to clozapine. These findings may limit the efficacy of clozapine as an hypnotic agent over an extended period of time. Further research on insomniac subjects is therefore indicated.

Adult↗

PubMed2026

Effect of atenolol versus ivabradine on heart rate variability in patients of schizophrenia with clozapine-induced tachycardia: a randomized controlled trial.

BACKGROUND: A third of schizophrenia cases are resistant to antipsychotics, where clozapine is the only FDA-approved medication. Clozapine use is often limited by intolerable adverse effects. Persistent tachycardia occurs in approximately 25-54% patients receiving clozapine. Heart rate variability (HRV) is a non-invasive, clinically relevant marker of autonomic nervous system functioning. Atenolol and Ivabradine are usually prescribed for clozapine-induced tachycardia (CIT), although evidence guiding their optimal use remains limited. AIM: This study aimed to compare the effects of atenolol versus ivabradine on HRV in patients with treatment-resistant schizophrenia (TRS) receiving clozapine. METHODS: This open-label randomised clinical trial, conducted at a tertiary-care center over 20 months, involved TRS patients on clozapine for more than three months and having persistent tachycardia. Twenty patients received atenolol 25mg once-daily, while twenty received ivabradine 5mg twice-daily for two months. The primary outcome was the change in the frequency domain of HRV, while the secondary outcomes were time-domains, central and peripheral blood pressure, pulse rate and treatment-emergent adverse events (TEAE). RESULTS: While both drugs significantly reduced pulse-rates (atenolol: -20.56±13.00, p<0.001; ivabradine: -21.855±12.873, p<0.001). Within-group analysis showed that, the atenolol group had significant improvements in high-frequency [HF] power (p=0.048) and LF/HF ratio (p=0.044), along with a non-significant trend towards increased total power (p=0.053); no significant within-group changes were observed in the ivabradine group. CONCLUSION: No significant between-group differences in HRV parameters were established between atenolol and ivabradine. Ivabradine could be a viable option in patients where atenolol is either contraindicated or not tolerated. Future larger multicentric studies are needed for greater generalisability. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06505668.

Humans↗

PubMedDate not supplied

Differential blockade of octopamine and dopamine receptors by analogues of clozapine and metoclopramide.

1. Sulpiride, but not procainamide, antagonizes the excitatory effects of (+/-)-octopamine receptors in the Tapes ventricle. Neither compound attenuates dopamine excitation. 2. Clozapine will attenuate the effects of (+/-)-octopamine and (-)-alpha-methyl octopamine at the octopamine receptor but not the excitatory effect of dopamine at dopamine receptors. 3. Clozapine is more potent than its 2-positional isomer HF 2046 in attenuating octopamine excitation. However, HF 2046, unlike clozapine, will attenuate the excitatory effects of dopamine. 4. These data indicate that replacement of the 8-chloro substituent in the clozapine nucleus with a 2-chloro substituent decreases the ability of the compound to blockaed octopamine receptors. However, the 2-chloro-substituted compound (HF 2046) now has the added ability to blockade excitatory dopamine receptors. 5. The greater potency of clozapine than HF 2046 as an octopamine antagonist suggests that it is the 8-chloro-substituted aromatic ring of clozapine which overlaps the aromatic site usually occupied by the octopamine aromatic ring.

Animals↗

PubMed1977

A psychophysiological investigation of the short-term effects of clozapine upon sleep parameters of normal young adults.

A nine consecutive night, double-blind design was used to assess the effects of a psychotropic agent (clozapine) upon sleep parameters as well as measures of mood and performance in a group of seven normal, young adults. Placebo was administered to a control group of seven subjects. EEGs and EOGs were monitored throughout the night in a laboratory environment and were scored according to standardized criteria. The administration of 25 mg clozapine/night for three consecutive nights significantly reduced stage 4 sleep on the second and third nights. Whereas stage REM sleep was not affected, a variety of REM indices were significantly increased on the third night of clozapine administration and/or on the first night of clozapine withdrawal. The number of body movements and the number of body movements/minute of sleep were significantly reduced on the three nights of clozapine administration. Numerous psychophysiological side effects were reported. These results indicate that clozapine may be a useful medication in the treatment of sleep disorders. However, the incidence of adverse side effects of represents a major limitation in the use of clozapine as an hypnotic agent at the dose-rate employed.

Adolescent↗

PubMed1976

[Acute and chronic effects of carpipramine, clozapine, haloperidol and sulpiride on the metabolism of biogenic amines in the rat brain (author's transl)].

In acute and chronic experiments investigations were made concerning the effect of clozapine, haloperidol, sulpiride and carpipramine on MHPG, HVA and 5-HIAA in rat brain and on motor activity of the animals. The activity of the rats treated with clozapine and haloperidol was reduced on the first day. After 10 days of treatment this effected of clozapine was significantly diminished. The MHPG level increased slightly on the first day of treatment with all four drugs. This elevation was maintained after chronic treatment with carpipramine and sulpiride, whereas clozapine and haloperidol decreased the MHPG content. 5-HIAA values did not show significant changes in acute experiments, whereas in chronic ones there was an increase. Haloperidol and clozapine induced a strong increase of HVA which decreased after 11 days in those animals treated with haloperidol. In comparison to haloperidol, after clozapine application the percentage of HVA-increase was higher in the limbic system than in the nigrostriatum.

Animals↗

PubMed1977

Role of clozapine in the occurrence of chromosomal abnormalities in human bone-marrow cells in vivo and in cultured lymphocytes in vitro.

Bone-marrow chromosomes were examined from 38 mentally and physically retarded and two psychiatric patients who were being treated with a variety of neuropharmacologic drugs. Twenty of these patients used clozapine (Leponex). The clastogenic effects of clozapine in vitro were studied in the lymphocyte cultures of three patients--one free of hematologic disease and two who 6 months earlier had had agranulocytosis attributed to the use of clozapine. The mean frequency of cytogenetic abnormalities in the bone-marrow cells of patients who used clozapine was significantly increased (P less than 0.05). The two patients who had had agranulocytosis had a greater frequency of cytogenetic abnormalities in their cultured lymphocytes in vivo and in vitro than the patient free of hematologic disease. A clone with a 13/14 chromosome translocation was detected in one of the patients. As all patients received a number of drugs during the in vivo and in vitro studies no definite conclusions could be drawn regarding the role played by clozapine in the occurrence of chromosomal abnormalities.

Adolescent↗

PubMed1976

Clozapine: reduction of the initial dopamine turnover increase by repeated treatment.

The levels of homovarillic acid and 3,4-dihydroxyphenylacetic acid in rat c. striatum after acute and 10 day administration of clozapine (30 and 100 mg/kg p.o.), thioridazine (100 mg/kg p.o.), haloperidol (1 mg/kg p.o.), and chlorpromazine (30 mg/kg p.o.), were estimated. With clozapine and haloperidol, the mesolimbic area was also investigated. With all these neuroleptics, the levels of both dopamine metabolites were reduced after a 10 day treatment as compared to acute administration, sometimes almost to control values. With clozapine, however, such a reduction occurred only with the higher dose of 100 mg/kg p.o., acting for a period longer than 24 h. This tolerance phenomenon was also observed with clozapine and haloperidol in the mesolimbic area. We conclude that clozapine is not qualitatively different from classical neuroleptics with respect to development of biochemical tolerance.

3,4-Dihydroxyphenylacetic Acid↗

PubMed1978

Comparative effects of clozapine and alpha-adrenoceptor blocking drugs on regional noradrenaline metabolism in rat brain.

Clozapine increased brain noradrenaline (NA) metabolism, as indicated by changes in 3-methoxy-4-hydroxyphenylglycol sulfate content, in brain regions corresponding to the predominance of alpha- over beta-receptors, i.e., hypothalamus, medulla, midbrain and cortex, but not corpus striatum or cerebellum. Phenoxybenzamine had a stronger effect in the hypothalamus than did clozapine, but did not change cortical NA metabolism within a 60 min treatment time; however, cortical NA metabolism was increased 150 min after phenoxybenzamine. The delayed effect of phenoxybenzamine may be due to either a poor affinity for some central receptors or a slow rate of entry into certain brain regions. Thioridazine and the benzodioxane, dibozane, had regional effects similar to clozapine. The similarity between clozapine and dibozane in ther effects on regional brain NA metabolism may reflect a preference for presynaptic alpha-receptors. It is unlikely that the antipsychotic activity of clozapine is related to a specific adrenolytic effect, but may reflect the combined activity of this drug on several transmitter systems.

Adrenergic alpha-Antagonists↗

PubMed1978

Discriminative stimulus properties of clozapine and chlorpromazine.

Rats were trained to discriminate pairs of drug states in a two-lever operant paradigm for food reinforcement. One group learned to discriminate clozapine from vehicle, a second group learned to discriminate chlorpromazine from vehicle, and a third group learned to discriminate clozapine from chlorpromazine. The result that the clozapine versus chlorpromazine discrimination was acquired, as well as the results of substitution tests with non-training drugs, suggest that the stimulus properties of the classical neuroleptics and other psychotherapeutic agents indicate that the stimulus properties of antipsychotics are distinct from other classes of psychotropic agents, and support the hypothesis that clozapine may be a unique antipsychotic. It is suggested that the unique discrimination stimulus produced by clozapine may be related to the differential effect of the drug on the extrapyramidal versus accumbens dopamine system.

Animals↗

PubMed1979

Effects of clozapine, chlorpromazine and haloperidol on schedule-controlled behavior.

The effects of clozapine, chlorpromazine, and haloperidol were determined in mice and pigeons responding under a multiple fixed-ratio 30, fixed-interval 600 sec schedule of food presentation. In both species, low doses were without effect and moderate to high doses of all three antipsychotics decreased responding. In contrast to other behavioral tests used to predict antipsychotic activity, clozapine was equipotent or more potent than chlorpromazine in decreasing responding under the multiple fixed-ratio 30, fixed-interval 600 sec schedule. The order of potency observed in the mouse was: haloperidol greater than chlorpromazine greater than or equal to clozapine. The order of potency in the pigeon was: haloperidol greater than clozapine greater than chlorpromazine. In mice and pigeons, the rate of responding under the fixed-ratio component was decreased at lower than, or the same doses of clozapine as that required to decrease fixed-interval responding. However, in both species, chlorpromazine and haloperidol decreased fixed-interval responding at lower doses or the same dose as that required to decrease fixed-ratio responding.

Animals↗

PubMed1977

Non-equilibrium method for the radioimmunoassay of clozapine in the presence of metabolites.

Cross-reactions with metabolites are an ever-recurring problem encountered in the use of radioimmunoassay techniques to determine active compounds in biological material. Metabolites may interfere with the assay of the parent drug to a variable extent. Taking 8-chloro-11-(4-methyl-1-piperazinyl)-5H-dibenzo[b,e][1,4]diazepine (clozapine as an example, it was shown that the extent to which the antiserum produced interacts with the parent drug and the metabolites can be estimated by determining the equilibrium constants and the kinetics. In the present case, therefore, it was advantageous to carry out the radioimmunoassay in disequilibrium, i.e. in order to differentiate the metabolites from the parent drug, the sample was incubated with the antiserum for 10 min, after which the labelled antigen was added and the reaction mixture again incubated for a brief, exactly timed interval. It was shown that cross-reactions did not occur in mixtures of clozapine and its N-demethyl and N-oxide metabolites in the propor tions 1:1:2 over a range of concentration of 1.5-48 ng clozapine per 100 microliter human plasma. The equilibrium constants measured with the clozapine goat antiserum were as follows: clozapine 1.2 X 10(8) M-1, the N-demethyl metabolite 4.6 X 10(7) M-1 and the N-oxide metabolite 3.7 X 10(7) M-1 (pH 7.5 and 20 degrees C).

Administration, Oral↗

PubMed1979

Effect of clozapine on human serum prolactin levels.

The authors determined serum prolactin levels in 13 patients receiving clozapine, an antipsychotic drug that does not produce extrapyramidal side effects. Morning serum prolactin levels, 11 hours after the last dose, were not elevated during chronic treatment with clozapine in any subject despite its therapeutic effects. Serum prolactin levels were moderately increased between 90 minutes and 4 hours after administration of very high doses of oral clozapine in 4 patients but were smaller than those produced by chlorpromazine in other subjects. The authors suggest that clozapine in other subjects. The authors suggest that clozapine may achieve its antipsychotic effect differently than do classical neuroleptics and that sustained prolactin increases are not essential for antipsychotic action.

Animals↗

PubMed1976

Double-blind comparison of clozapine with chlorpromazine in acute schizophrenic illness.

Double Blind comparative trial of a new dibenzodiazepine derivative Clozapine (Leponex) with Chlorpromazine was conducted in the treatment of acute schizophrenic illness over a 6 week period. Factor Analysis of ratings in 9 matched pairs indicates that Clozapine, at 300 mg. per day, is comparable in efficacy to Chlorpromazine in all factors except "Irritability" for which Clozapine appears to be superior. Illness severity and Global Change ratings in all patients showed that Clozapine is more effective in producting a shift towards improvement at the end of 6 weeks. Major side effects reported in Clozapine confirmed sedation and hypersalivation as consistent problems and presence of rigidity and tremor (extra-pyramidal) being at variance with other studies.

Acute Disease↗

PubMed1977

[Frequent cases of agranulocytosis due to clozapin (leponex) in eastern Switzerland].

Two personally observed cases of severe agranulocytosis within 3 months, one of them fatal, could be attributed to the new dibenzodiazepine derivative Clozapine (Leponex). Clozapine, a very effective neuroleptic for the treatment of acute and chronic schizophrenia, has been found before to induce agranulocytosis of the metabolic type, as phenothiazines are known to do. An inquiry in al Swiss medical departments and mental hospitals revealed a total of 20 cases of Clozapine induced agranulocytosis in some 50% of institutions responding. 9 of these were observed in Eastern Switzerland. This time-space clustering recalls the "finnish epidemic" of 1975 in Southern Finland. Possible explanations for this phenomenon are discussed. Calculations of the incidence suggest a higher rate of agranulocytosis induced by Clozapine than has been assumed for the phenothiazines. Clozapine should therefore be restricted to schizophrenic patients and initially (6 weeks) be given only on a stationary basis under regular blood controls.

Adult↗