clozapine and Pericarditis

Topics: Adolescent; Antipsychotic Agents; Benzodiazepines; Brain; Cardiomyopathies; Child; Clozapine; Dyskinesia, Drug-Induced; Energy Metabolism; Feeding Behavior; Female; Gene Expression; Genetic Association Studies; Humans; Male; Myocarditis; Olanzapine; Pericarditis; Risperidone; Tourette Syndrome; Twin Studies as Topic; Weight Gain

Clozapine is known to cause cardiac side-effects, including myocarditis, pericarditis and cardiomyopathy. Prompted by a case of clozapine-related pericarditis in our hospital we undertook a review of the literature for reports of myocarditis, pericarditis and cardiomyopathy occurring in patients treated with clozapine. This is the first comprehensive review of the literature on this topic.

Topics: Cardiomyopathies; Clozapine; Humans; Myocarditis; Pericarditis

Clozapine-induced myocarditis and pericarditis are uncommon adverse effects of clozapine treatment. However, in most cases, they lead to clozapine discontinuation. Here, we describe a case of successful clozapine rechallenge after clozapine-induced myopericarditis. The patient, a 31-year-old male with treatment-resistant schizophrenia (TRS), developed dyspnea on exertion and chest pain on day 19 after the start of clozapine titration. An electrocardiogram (ECG) showed widespread, mild, convex ST interval elevation. While troponin levels were mildly elevated, the echocardiogram was unremarkable. A myopericarditis diagnosis was formulated, and clozapine was stopped, with a progressive resolution of clinical, laboratory and ECG abnormalities. After 6 months, a rechallenge with clozapine was attempted. A very slow titration scheme was adopted, along with close monitoring of clinical, laboratory and ECG parameters. Clozapine target dose was reached without the occurrence of any abnormality. Given the unique role of clozapine in the management of TRS, clozapine rechallenge may be considered after pericarditis, even with troponin levels elevation. Further studies are needed to update current clinical guidelines.

Topics: Adult; Antipsychotic Agents; Clozapine; Humans; Male; Myocarditis; Pericarditis; Troponin

Clozapine is a second-generation antipsychotic often used for treatment-refractory schizophrenia and has many adverse effects. Cardiac adverse events potentiated by clozapine include myocarditis which is a black box warning. Even more rarely, there are multiple cases of pericarditis reported in the literature. This is a case report of a 32-year old male with paranoid schizophrenia who developed pericarditis after initiation and titration of clozapine in the inpatient psychiatry unit. Patient presented with chest pain, persistent tachycardia, and orthostatic hypotension two weeks after titration of clozapine. The diagnosis of pericarditis was supported by the repeat electrocardiogram which revealed PR depressions, the audible friction rub, and the pleuritic/episodic nature of the chest pain. All other possible causes of pericarditis were ruled out and clozapine was suspected as the most likely explanation. The pericarditis resolved with treatment of colchine and ibuprofen on evidence from a repeat echocardiogram. This case report demonstrates and supports few cases of clozapine induced pericarditis in the literature. Cardiac events of clozapine can be life-threatening; therefore, greater baseline and subsequent cardiac monitoring may be implicated in the future.

Topics: Adult; Antipsychotic Agents; Clozapine; Humans; Male; Myocarditis; Pericarditis; Schizophrenia, Paranoid

Clozapine is an atypical antipsychotic used most frequently in the management of treatment-resistant schizophrenia, where severely unwell patients have failed to respond to standard antipsychotic therapy. Clozapine is associated with a number of risks, such as agranulocytosis and long-term cardiometabolic morbidity. Reported less frequently is the risk of severe cardiac complications. The case reported here provides an important example of chronic clozapine toxicity leading to pericarditis. This case also describes a difficult ethical dilemma, where the physical risk to a patient with a diagnosis of schizophrenia must be balanced with the potentially adverse psychiatric risk that would follow, if the patient were to be weaned off this effective antipsychotic therapy. It is frequently reported that clozapine is stopped due to its toxicity. In this case however, the mental health and functional benefit of continuing with clozapine was deemed to outweigh the physical risk of progression of the pericarditis.

Topics: Antipsychotic Agents; Clozapine; Echocardiography; Ethics, Professional; Humans; Male; Middle Aged; Pericarditis; Schizophrenia

Using national Danish registers, we estimated rates of clozapine-associated cardiac adverse events. Rates of undiagnosed myocarditis were estimated by exploring causes of death after clozapine initiation.. Through nationwide health registers, we identified all out-patients initiating antipsychotic treatment (January 1, 1996-January 1, 2015). Rates of clozapine-associated myocarditis and pericarditis within 2 months from clozapine initiation and rates of cardiomyopathy within 1-2 years from clozapine initiation were compared to rates for other antipsychotics. Mortality within 2 months from clozapine initiation was extracted.. Three thousand two hundred and sixty-two patients of a total 7932 patients initiated clozapine as out-patients (41.12%). One patient (0.03%) developed myocarditis, and no patients developed pericarditis within 2 months from clozapine initiation. Two (0.06%) and four patients (0.12%) developed cardiomyopathy within 1 and 2 years respectively. Rates were similar for other antipsychotics. Twenty-six patients died within 2 months from clozapine initiation. Pneumonia (23.08%) and stroke (11.54%) were the main causes of death. We estimated the maximum rate of clozapine-associated fatal myocarditis to 0.28%.. Cardiac adverse effects in Danish out-patients initiating clozapine treatment are extremely rare and these rates appear to be comparable to those observed for other antipsychotic drugs.

Topics: Adult; Aged; Ambulatory Care; Antipsychotic Agents; Bipolar Disorder; Cardiomyopathies; Clozapine; Denmark; Female; Humans; Male; Middle Aged; Myocarditis; Pericarditis; Psychotic Disorders; Registries; Schizophrenia

Clozapine is the archetypical atypical antipsychotic, its primary indication being treatment resistant schizophrenia. Severe side effects caused by clozapine, including leukopenia, agranulocytosis, and myocarditis, are well known. A rarely described side effect is concurrent perimyocarditis and parenchymal lung disease.. A previously physically healthy 23-year-old male Caucasian that suffered from schizophrenia presented with flu-like symptoms 1 week after starting clozapine treatment. Treatment with clozapine was discontinued. He developed respiratory distress. Investigations showed significant parenchymal infiltration in both of the lungs, pericardial fluid, and heart failure. He initially received treatment for suspected malignant neuroleptic syndrome and later for suspected infection, but these tentative diagnoses were not confirmed. The patient's condition gradually improved. In retrospect, clozapine-induced parenchymal lung disease and perimyocarditis were deemed the most probable causes.. Concurrent perimyocarditis and parenchymal lung disease are rare side effects of clozapine. Clozapine-induced disease in general is considered an exclusion diagnosis. Lacking a verifiable diagnosis when suspecting a side effect of clozapine, clinicians might treat the most likely and serious condition presenting and consider discontinuing clozapine until the diagnostic uncertainty is reasonably resolved.

Topics: Adult; Antipsychotic Agents; Clozapine; Diagnosis, Differential; Humans; Lung Diseases; Male; Myocarditis; Pericarditis; Schizophrenia; Young Adult

We report the case of a multiple drug interaction involving clozapine, antifungals and oral contraceptives, which resulted in an increased clozapine plasma level, pericarditis with pericardial effusion and eosinophilia in a young Caucasian woman. These symptoms and signs disappeared a few days after discontinuation of clozapine. At present, we are not aware of reports of clozapine-antifungals interaction, whereas there is only one other case report on the interaction between oral contraceptives and clozapine. The purpose of this case report is to show the risk of potentially serious adverse effects stemming from drug interactions involving medications routinely used in clinical practice.. A 29-year-old Caucasian woman diagnosed with a schizoaffective disorder was admitted to a psychiatric unit for acute psychosis (hallucinations, delusions and catatonic behavior). She denied smoking tobacco products and was on long-term oral contraceptives. During the first month of hospitalization she was treated with antipsychotics and for 1 week she took simultaneously fluconazole and miconazole gel, after being diagnosed with oral candidiasis. On the last day of antifungals treatment, 29 days after admission, clozapine was started with resolution of psychotic symptoms. After 3 weeks, her clozapine plasma level had increased to 542 ng/mL and eosinophilia was observed. She complained of nausea, vomiting and palpitations; echocardiography showed echocardiographic abnormalities and pericardial effusion. Oral contraceptives were discontinued and after 1 week clozapine was interrupted, with a complete resolution of side effects and pericardial effusion within 4 days.. Clozapine is metabolized by cytochrome P450. The use of inhibitors or other substrates of cytochrome P450, such as antifungals and oral contraceptives, can cause long-lasting interactions and clozapine toxicity. The Naranjo algorithm shows clozapine is a definite cause of pericarditis (score 9) and both clozapine-antifungals and clozapine-contraceptives interactions resulted probable (score 5) in Drug Interaction Probability Scale. A good knowledge on drugs that act as substrates, inhibitors or inducers of cytochrome P450 is mandatory. When those drugs are used in patients taking clozapine, blood level monitoring of clozapine should be recommended, since a lower dose of clozapine might be required to prevent clozapine toxicity.

Topics: Adult; Antifungal Agents; Antipsychotic Agents; Clozapine; Contraceptives, Oral; Drug Interactions; Eosinophilia; Female; Humans; Pericardial Effusion; Pericarditis; Psychotic Disorders; Tachycardia, Sinus

Topics: Adult; Antipsychotic Agents; Clozapine; Drug Resistance; Drug Therapy, Combination; Humans; Indomethacin; Male; Pericarditis; Schizophrenia; Valproic Acid

Topics: Antipsychotic Agents; Clozapine; Female; Humans; Middle Aged; Pericarditis; Schizophrenia

To report a case of a patient treated with clozapine who developed pericarditis with pericardial effusion that resolved when the drug was discontinued.. Case report of a 21-year-old man with psychotic disorder that had been stable on clozapine therapy for five months (after failure of atypical antipsyhotic agents) presented to the emergency department complaining of chest pain and progressive shortness of breath that had lasted for a few days. Echocardiography showed a pericardial effusion suggestive of a cardiac tamponade, and the fluid was removed by pericardiocentesis. All other possible causes of the pericardial effusion were ruled out and clozapine was suspected as the most likely explanation. Clozapine was discontinued and the patient's symptoms improved markedly.. According to the Naranjo probability scale, clozapine is a probable cause of pericarditis. Although clozapine is a known cause of myocarditis and cardiomyopathy, there are only several reports in the literature describing clozapine-induced pericarditis and pericardial effusion. In our patient, the pericardial effusion cleared within several days following clozapine discontinuation.. There have been only a few cases of clozapine-induced pericarditis reported in the literature, however this adverse effect of clozapine can occur, as this case report clearly demonstrates. Cardiac adverse effects of clozapine are potentially life threatening, hence early recognition is essential to prevent serious outcomes.

Topics: Adult; Antipsychotic Agents; Clozapine; Echocardiography; Humans; Male; Pericardial Effusion; Pericarditis

Idiosyncratic reactions are serious, unpredicted adverse effects of antiepileptic drugs which are in use in psychiatry as mood stabilizers. Severe idiosyncratic reactions can manifest as systemic symptoms or Dress syndrome clinically manifested with increased body temperature, peripheral lymphadenopathy and potential one or multiple organ failure. We present a 36 years old patient, who was hospitalized for the first time in our hospital after he attempted suicide by hanging. Patient was diagnosed as Bipolar affective disorder, current episode depressive with psychotic features and high suicidal risk. At the time of admission he was taking olanzapine and venlafaxine. Psychopharmacs were cross titrated to clozapine, valproic acid and lamotrigine. Two weeks later, patient's mood was stabilized but his somatic status worsened dramatically. He was forwarded to Clinic for Infective Diseases where he was diagnosed with severe sepsis. Dress syndrome, although initially suspected was not verified, but has to be taken into consideration in each patient prescribed with antiepileptic drugs.

Topics: Adult; Anticonvulsants; Antipsychotic Agents; Bipolar Disorder; Clozapine; Diagnosis, Differential; Drug Therapy, Combination; Humans; Lamotrigine; Male; Pericarditis; Respiratory Insufficiency; Systemic Inflammatory Response Syndrome; Triazines; Valproic Acid

Topics: Adolescent; Antipsychotic Agents; Clozapine; Cooperative Behavior; Humans; Interdisciplinary Communication; Male; Patient Care Team; Pericardial Effusion; Pericarditis; Referral and Consultation; Retreatment; Schizophrenia, Paranoid; Tachycardia, Sinus

Clozapine is a valuable drug for patients with treatment-resistant schizophrenia. Myocarditis is the most publicised cardiac complication of clozapine treatment, but cardiomyopathy and pericarditis have also been reported. Myocarditis has heterogeneous and non-specific presenting features, making it difficult to identify patients with clozapine-related myocarditis clinically. A high index of suspicion is required. The gold standard for diagnosis of myocarditis is an endomyocardial biopsy, but this is not a practical initial approach. Transthoracic echocardiography is a valuable, reproducible and widely available tool to assist in diagnosis of clozapine-induced cardiotoxicity. The level of B-type natriuretic peptide, a hormone secreted in response to ventricular wall stress, may be useful for evaluating patients with clozapine-induced cardiac dysfunction and may in the future be useful for screening asymptomatic patients. The mainstay of treatment of clozapine-induced cardiotoxicity is cessation of clozapine and provision of supportive care.

Topics: Antipsychotic Agents; Clozapine; Humans; Myocarditis; Pericarditis; Risk Factors; Schizophrenia

Clozapine is used in the treatment of resistant schizophrenia. It is used as a reserve drug mainly because of its adverse effect profile affecting gastrointestinal, haematological and cardiorespiratory systems. Cardiac side effects are uncommon but could be potentially life threatening, hence early recognition and active monitoring are essential to prevent serious cardiac side effects. A case of pericarditis with pericardial effusion is described in a patient who was recently started on clozapine which disappeared within 1 week after discontinuation of clozapine.

Topics: Adult; Antipsychotic Agents; Clozapine; Electrocardiography; Humans; Male; Pericardial Effusion; Pericarditis; Schizophrenia; Ultrasonography

Topics: Adult; Antipsychotic Agents; Clozapine; Eosinophilia; Humans; Male; Pericarditis; Schizophrenia

Topics: Adult; Anticonvulsants; Antipsychotic Agents; Cardiac Tamponade; Clozapine; Drug Eruptions; Drug Therapy, Combination; Female; Humans; Pericardial Effusion; Pericarditis; Pleural Effusion; Schizophrenia; Serositis; Valproic Acid

Clozapine is known to cause cardiac side effects, including myocarditis, pericarditis, and cardiomyopathy. Prompted by a case of clozapine-related pericarditis in an adolescent, we undertook a retrospective chart review to discover whether any unrecognized cases of myocarditis, pericarditis, or cardiomyopathy were among the children, adolescents, and young adults we had treated with clozapine. The sample comprised a total of 36 patients, who were monitored regularly over a period ranging from 2.5 to 79 months. The average observation period was 7.5 months. Patients were assessed for potential indicators of myocarditis, pericarditis, or cardiomyopathy. In more than 66% of all patients, at least one of several parameters potentially indicative of pericarditis, myocarditis, or cardiomyopathy was abnormal in at least one instance during the observation period. In all cases in which abnormalities were discovered, the abnormalities were found to be unspecific for myocarditis, pericarditis, or cardiomyopathy. With the exception of the case which prompted our study, none of the patients were found to have developed any such disorder in the course of further treatment with clozapine.

Topics: Adolescent; Antipsychotic Agents; Aspartate Aminotransferases; Body Temperature; Cardiomyopathies; Child; Clozapine; Creatine Kinase; Electrocardiography; Female; Humans; L-Lactate Dehydrogenase; Leukocyte Count; Male; Myocarditis; Pericarditis; Retrospective Studies; Schizophrenia

A case report describes an adolescent girl with a treatment-resistant bipolar disorder, who developed pericarditis and polyserositis while being treated with clozapine. The sparse literature about this rare, severe side effect of clozapine is discussed. Clinical recommendations with regard to monitoring are given. If myocarditis/polyserositis occurs, clozapine has to be discontinued immediately.

Topics: Adolescent; Agranulocytosis; Antipsychotic Agents; Bipolar Disorder; Clozapine; Female; Humans; Pericarditis; Psychiatric Status Rating Scales; Serositis

Topics: Adult; Antipsychotic Agents; Clozapine; Follow-Up Studies; Humans; Male; Pericardial Effusion; Pericardiocentesis; Pericarditis; Schizophrenia, Paranoid; Treatment Outcome

Topics: Adolescent; Antipsychotic Agents; Clozapine; Electrocardiography; Female; Humans; Myocarditis; Pericarditis; Schizophrenia; Troponin I

Topics: Adult; Antipsychotic Agents; Clozapine; Dose-Response Relationship, Drug; Electrocardiography; Humans; Male; Myocarditis; Pericarditis; Schizophrenia, Paranoid

Topics: Adult; Arrhythmias, Cardiac; Clozapine; Dibenzazepines; Endocarditis; Humans; Male; Pericarditis; Schizophrenia