Clozapine-Associated Myocarditis

Haas, Steven Joseph; Hill, Richard L.; Krum, Henry; Liew, Danny; Tonkin, Andrew; Demos, Lisa; Stephan, Karen; McNeil, John J

doi:10.2165/00002018-200730010-00005

Cited by 178 publications

(70 citation statements)

References 32 publications

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“…As a general rule, clozapine should always be suspected as a potential culprit when a patient develops new or worsened physical symptoms, in particular when the symptoms point to a systemic process and appear in the early stages of treatment. Most cases of myocarditis, pericarditis and lung disease seem to develop within 2 to 3 weeks of commencing clozapine [20]. It should also be taken into account that the concomitant use of psychotropic drugs adds to the risk of developing serious adverse effects, as does comorbid metabolic syndrome, heart and lung disease [21–25].…”

Section: Discussionmentioning

confidence: 99%

Probable clozapine-induced parenchymal lung disease and perimyocarditis: a case report

2016

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BackgroundClozapine 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.Case presentationA 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.ConclusionsConcurrent 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.

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Section: Discussionmentioning

confidence: 99%

Probable clozapine-induced parenchymal lung disease and perimyocarditis: a case report

2016

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“…Incidence of clozapine induced myocarditis has been estimated to be as high as approximately 1% of patients starting clozapine92 although others have found a lower incidence of about one in five hundred 93. It should be noted that although no definitive increased risk for myocarditis has been identified with other agents, quetiapine has been raised as a possible cause in several reported cases of myocarditis as well 94…”

Section: Myocarditismentioning

confidence: 99%

“…The majority of clozapine-induced myocarditis occurs within the first 4 weeks of treatment, usually between days 14 and 21, although cases have been reported more than a year after treatment initiation 92,95. No specific monitoring guidelines have been recommended in the United States although guidelines have been proposed in Australia including baseline C-reactive protein (CRP), cardiac enzymes, and echocardiography 95…”

Section: Myocarditismentioning

confidence: 99%

Managing cardiovascular disease risk in patients treated with antipsychotics: a multidisciplinary approach

Shulman

Miller

Misher

et al. 2014

JMDH

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BackgroundThe use of antipsychotic medication in the United States and throughout the world has greatly increased over the last fifteen years. These drugs have significant side effect burdens, many of them relating to cardiovascular health.ObjectiveTo review the available evidence on the major cardiovascular issues that arise in patients taking antipsychotic medication.MethodA PubMed literature review was performed to identify recent meta-analyses, review articles, and large studies. Further articles were identified through cited papers and based on expert consultation when necessary.ResultsClinical guidance on the following adverse effects and antipsychotics was reviewed: electrocardiogram (ECG) changes, (specifically, prolonged QT and risk of torsades de pointes), weight gain, dyslipidemia, metabolic syndrome, and myocarditis. Specific attention was paid to monitoring guidelines and treatment options in the event of adverse events, including dose change, medication switch, or adjuvant therapy.

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“…Another study reported the incidence rate of any clozapine adverse reactions to be 0.7–1.2% among treated patients (4). The psychiatry unit of the hospital in question could accommodate up to 27 psychiatric patients at a given time.…”

Section: Discussionmentioning

confidence: 99%

“…Myocarditis may be related to clozapine dosages between 100 and 450 mg (4). The US FDA Report from the 1990s suggested that the median daily clozapine dose of 450 mg was observed in patients who survived and 400 mg of patients who died from clozapine-induced myocarditis (2).…”

Section: Discussionmentioning

confidence: 99%

Clozapine-associated cardiac dysfunction during a gastroenteritis outbreak

Szema

Marboe

Fritz

et al. 2016

Journal of Community Hospital Internal Medicine Perspectives

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We report that two young adult patients who were initiated with clozapine for severe psychosis during a hospital-wide gastroenteritis outbreak went into severe shock. Neither patient had troponin elevation. Each required left ventricular assist device support for myocarditis. Endomyocardial biopsy revealed lymphocytic myocarditis in one patient and eosinophilic myocarditis in the other. The former patient expired. Polymerase chain reaction testing was negative for Coxsackie virus. These two patients illustrate that myocarditis can occur at usual incipient doses and that there may be an epidemiologic risk associated with gastroenteritis. Although the white blood cell (WBC) count is expected to decrease with clozapine, these patients had persistently elevated WBC counts. In conclusion, physicians should exercise caution when prescribing clozapine, especially for those with diarrhea.

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Clozapine-Associated Myocarditis

Cited by 178 publications

References 32 publications

Probable clozapine-induced parenchymal lung disease and perimyocarditis: a case report

Probable clozapine-induced parenchymal lung disease and perimyocarditis: a case report

Managing cardiovascular disease risk in patients treated with antipsychotics: a multidisciplinary approach

Clozapine-associated cardiac dysfunction during a gastroenteritis outbreak

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