clozapine and Bradycardia

Postanesthesia bradycardia or asystole before electroconvulsive therapy (ECT) occurs very infrequently but is a potentially fatal complication of pre-ECT anesthesia. The optimal strategy for the prevention of its recurrence is unclear because the use of premedication with atropine may not always be successful. In this article, we present the case of a 21-year-old man with schizophrenia who developed bradycardia directly after receiving succinylcholine during the first 3 ECT sessions. Replacing succinylcholine with mivacurium seemed to be a successful strategy in preventing bradycardia during the final 9 ECT sessions.

Topics: Alfentanil; Anesthesia, General; Anesthetics, Intravenous; Antipsychotic Agents; Bradycardia; Clozapine; Electroconvulsive Therapy; Etomidate; Humans; Isoquinolines; Male; Mivacurium; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Schizophrenia; Succinylcholine; Young Adult

Topics: Anti-Anxiety Agents; Antipsychotic Agents; Bradycardia; Clozapine; Diazepam; Drug Interactions; Drug Therapy, Combination; Electrocardiography; Humans; Male; Middle Aged; Schizophrenia, Paranoid; Syncope

Topics: Adult; Age Factors; Aged; Bradycardia; Cardiovascular Diseases; Clozapine; Drug Administration Schedule; Humans; Psychotic Disorders; Respiration Disorders

Clozapine is an atypical antipsychotic agent that is effective in refractory schizophrenic patients. Older patients may have various psychotic manifestations that may not be responsive to typical neuroleptic therapy. There may also be patient-specific factors--declines in reserve capacity and homeostasis, and age-related changes in the pharmacokinetics and pharmacodynamics of drugs--in older patients that increase their susceptibility to the side effects of psychotropic medications. While clozapine has few extrapyramidal side effects, it has other side effects that may be problematic in the older population.. In our geropsychiatric unit, clozapine was prescribed for four patients over the age of 65 years. All patients were either experiencing psychotic symptoms refractory to other antipsychotic medications or had relative contraindications to a typical neuroleptic. Two of the four were chronic schizophrenics, and three of the four also presented with dementia.. Two of the four patients did eventually receive relief of psychotic symptoms from clozapine. All four experienced events after initiation of clozapine therapy, which included falls (2 patients), symptomatic bradycardia (2 patients), and delirium (1 patient). All these adverse effects occurred on doses ranging from 6.25 to 37.50 mg/day, and the three patients with moderate-to-severe dementia experienced these severe adverse effects after administration of the first dose.. Clozapine may be a useful drug for older patients with psychotic symptoms; however, at current dosage recommendations, adverse events may occur, especially on first dose. Well-designed studies need to be performed to assess the effectiveness and dosage ranges for this population.

Topics: Accidental Falls; Age Factors; Aged; Aged, 80 and over; Bradycardia; Clozapine; Delirium; Dementia; Female; Hospitalization; Humans; Male; Schizophrenia; Schizophrenic Psychology; Severity of Illness Index; Treatment Outcome