Abstract
Background: The most serious adverse effect of clozapine, agranulocytosis, was described for the first time in Finland in 1975. It caused the immediate withdrawal of clozapine from the market and immediate discontinuation of this medication in all patients. It is now known that abrupt withdrawal of clozapine may cause a rapid deterioration in psychotic symptoms.
Objective: The aim of this retrospective study was to investigate the effect of abrupt clozapine withdrawal on psychiatric patients, and to examine whether anticholinergic drugs are effective in preventing acute deterioration.
Materials and methods: We reviewed the hospital case records from Pitkäniemi Psychiatric Hospital, Tampere, Finland, of the 28 patients with schizophrenia who had been receiving clozapine and from whom it was abruptly withdrawn due to the withdrawal of the drug from the market in the summer of 1975. We assessed the incidence of deterioration and whether or not patients in whom this occurred were receiving anticholinergic drugs.
Results: We found a rapid deterioration after clozapine withdrawal in almost half (46.4%; n = 13) of the patients. Patients receiving anticholinergic drugs (such as antiparkinsonians, tricyclic antidepressants and antipsychotics with anticholinergic properties) were significantly less likely to deteriorate than those not receiving these drugs (21.4% vs 71.4%, p = 0.008). The condition of the patients who deteriorated was poor for up to 1 month after discontinuation, but had improved slightly by the end of 1975.
Conclusion: Anticholinergic medication should be considered for preventing possible symptom deterioration when clozapine is abruptly discontinued.
Similar content being viewed by others
References
Wagstaff A, Bryson H. Clozapine: a review of its pharmacological properties and therapeutic use in patients with schizophrenia who are unresponsive to or intolerant of classical antipsychotic agents. CNS Drugs 1995; 5(5): 370–400
Wagstaff A, Perry C. Clozapine: in prevention of suicide in patients with schizophrenia or schizoaffective disorder. CNS Drugs 2003; 17(4): 273–80
Lieberman JA, Safferman AZ. Clinical profile of clozapine: adverse reactions and agranulocytosis. Psychiatr Q 1992 Spring; 63(1): 51–70
Ereshefsky L. Pharmacokinetics and drug interactions: update for new antipsychotics. J Clin Psychiatry 1996; 57Suppl. 11: 12–25
Buchanan RW. Clozapine: efficacy and safety. Schizophr Bull 1995; 21(4): 579–91
Idänpään-Heikkilä J, Alhava E, Olkinuora M, et al. Agranulocytosis during treatment with clozapine. Eur J Clin Pharmacol 1977 Mar; 11(3): 193–8
Kuha S. The consequences of sudden stopping of clozapine in Finland [abstract]. Proceedings of the Sixth World Congress of Psychiatry 1977; American Psychiatric Association; Honolulu
Weiden PJ, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull 1995; 21(3): 419–29
Csernansky JG, Schuchart EK. Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics. CNS Drugs 2002; 16(7): 473–84
Ekblom B, Eriksson K, Lindström LH. Supersensitivity psychosis in schizophrenic patients after sudden clozapine withdrawal. Psychopharmacol (Berl) 1984; 83(3): 293–4
Shiovitz TM, Welke TL, Tigel PD, et al. Cholinergic rebound and rapid onset psychosis following abrupt clozapine withdrawal. Schizophr Bull 1996; 22(4): 591–5
Ahmed S, Chengappa KN, Naidu VR, et al. Clozapine withdrawal-emergent dystonias and dyskinesias: a case series. J Clin Psychiatry 1998 Sep; 59(9): 472–7
Stanilla JK, de Leon J, Simpson GM. Clozapine withdrawal resulting in delirium with psychosis: a report of three cases. J Clin Psychiatry 1997 Jun; 58(6): 252–5
Zesiewicz TA, Borra S, Hauser RA. Clozapine withdrawal symptoms in a Parkinson’s disease patient. Mov Disord 2002 Nov; 17(6): 1365–7
Lee JW, Robertson S. Clozapine withdrawal catatonia and neuroleptic malignant syndrome: a case report. Ann Clin Psychiatry 1997 Sep; 9(3): 165–9
Yeh AW, Lee JW, Cheng TC, Wen JK, Chen WH. Clozapine withdrawal catatonia associated with cholinergic and serotonergic rebound hyperactivity: a case report. Clin Neuropharmacol 2004 Sep–Oct; 27(5): 216–8
Gerlach J, Koppelhus P, Helweg E, et al. Clozapine and haloperidol in a single-blind cross-over trial: therapeutic and biochemical aspects in the treatment of schizophrenia. Acta Psychiatr Scand 1974; 50(4): 410–24
Diamond BI, Borison RL. Basic and clinical studies of neuroleptic-induced supersensitivity psychosis and dyskinesia. Psychopharmacol Bull 1986; 22(3): 900–5
Borison RL, Diamond BI, Sinha D, et al. Clozapine withdrawal rebound psychosis. Psychopharmacol Bull 1988; 24(2): 260–3
Meltzer HY, Lee MA, Ranjan R, et al. Relapse following clozapine withdrawal: effect of neuroleptic drugs and cyproheptadine. Psychopharmacology (Berl) 1996 Mar; 124(1-2): 176–87
Tollefson GD, Dellva MA, Mattler CA, et al. Controlled, double-blind investigation of the clozapine discontinuation symptoms with conversion to either olanzapine or placebo. J Clin Psychopharmacol 1999 Oct; 19(5): 435–43
Chouinard G, Jones BD, Annable L. Neuroleptic-induced supersensitivity psychosis. Am J Psychiatry 1978 Nov; 135(11): 1409–10
Eklund K. Supersensitivity and clozapine withdrawal. Psychopharmacology (Berl) 1987; 91(1): 135
Parsa MA, al-Lahham YH, Ramirez LF, et al. Prolonged psychotic relapse after abrupt clozapine withdrawal. J Clin Psychopharmacol 1993 Apr; 13(2): 154–5
de Leon J, Henighan V, Stanilla JK, et al. Clozapine levels after clozapine discontinuation. J Clin Psychopharmacol 1996 Apr; 16(2): 193–4
Tanriverdi N, Yazici KM. Immediate recurrence of psychotic symptoms after discontinuation of clozapine: a case report. Biol Psychiatry 1996 May 1; 39(9): 814–5
Shore D. Clinical implications of clozapine discontinuation: report of an NIMH workshop. Schizophr Bull 1995; 21(2): 333–7
Davis JM. Overview: maintenance therapy in psychiatry: I. Schizophrenia. Am J Psychiatry 1975 Dec; 132(12): 1237–45
Gilbert PL, Harris MJ, McAdams LA, et al. Neuroleptic withdrawal in schizophrenic patients: a review of the literature. Arch Gen Psychiatry 1995 Mar; 52(3): 173–88
Seeman P, Tallerico T. Rapid release of antipsychotic drugs from dopamine D2 receptors: an explanation for low receptor occupancy and early clinical relapse upon withdrawal of clozapine or quetiapine. Am J Psychiatry 1999 Jun; 156(6): 876–84
Guy W. ECDEU Assessment manual for psychopharmacology. Rockville (MD): National Institute of Mental Health, 1976: 218-22
Taylor P. Cholinergic agonists. In: Gilman GA, Rall TW, Nies AS, et al., editors. Goodman and Gilman’s the pharmacological basis of therapeutics. 8th ed. New York: Pergamon Press, 1990: 122–30
Linszen DH, Dingemans PM, Lenior ME, et al. Relapse criteria in schizophrenic disorders: different perspectives. Psychiatry Res 1994 Dec; 54(3): 273–81
Bazire S. Psychotropic drug directory 2002. Snow Hill, Dinton: Mark Allen Publishing Ltd, 2001
de Leon J, Stanilla JK, White AO, et al. Anticholinergics to treat clozapine withdrawal. J Clin Psychiatry 1994 Mar; 55(3): 119–20
Meltzer HY. Clozapine withdrawal: serotonergic or dopaminergic mechanisms? Arch Gen Psychiatry 1997 Aug; 54(8): 760–1
Baldessarini RJ, Gardner DM, Garver DL. Conversions from clozapine to other antipsychotic drugs. Arch Gen Psychiatry 1995 Dec; 52(12): 1071–2
Kane J, Honigfeld G, Singer J, et al. Clozapine for the treatment-resistant schizophrenic: a double-blind comparison with chlorpromazine. Arch Gen Psychiatry 1988 Sep; 45(9): 789–96
Acknowledgements
The authors acknowledge Ms Johanna Varsamäki for excellent secretarial assistance, Ms Anna-Maija Koivisto B.A. for statistical assistance, and Ms Virginia Mattila M.A. for language checking. Financial support for this study was received from Satakuna Hospital District Research Foundation. The authors have no conflicts of interest that are directly relevant to the content of this study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Seppälä, N., Kovio, C. & Leinonen, E. Effect of Anticholinergics in Preventing Acute Deterioration in Patients Undergoing Abrupt Clozapine Withdrawal. CNS Drugs 19, 1049–1055 (2005). https://doi.org/10.2165/00023210-200519120-00006
Published:
Issue Date:
DOI: https://doi.org/10.2165/00023210-200519120-00006