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Clozapine, Agranulocytosis, and Benign Ethnic Neutropenia

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Clozapine, Agranulocytosis, and Benign Ethnic Neutropenia EDITORIAL 545 Postgrad Med J: first published as 10.1136/pgmj.2004.031641 on 2 September 2005. Downloaded from Pharmacology and toxicology ethnic groups in the Middle East, ....................................................................................... including Yemenite Jews and Jordanians, have BEN.12 13 BEN has only been reported in ethnic groups that have Clozapine, agranulocytosis, and tanned or dark skin.13 Subjects with BEN do not show increased incidence of benign ethnic neutropenia infections, and their response to infec- tions is similar to those without BEN.13 S Rajagopal ................................................................................... CLINICAL IMPLICATIONS In the United Kingdom and Ireland, the Current knowledge and clinical implications Clozaril patient monitoring service (CPMS) supervises the prescribing of clozapine and the haematological test- lozapine is an atypical antipsycho- agranulocytosis, is more common in ing (Clozaril is the brand name of tic that is effective in treatment black people.6 A white cell count spike clozapine). The CPMS uses a lower cut resistant schizophrenia.1 The of 15% or more above the immediately C off point for patients with BEN than for National Institute for Health and preceding measurement may predict the general population (table 1). A Clinical Excellence (NICE) guidelines agranulocytosis within the next ‘‘green’’ alert indicates satisfactory for schizophrenia specify that ‘‘in indi- 75 days.7 However, as these differences count, an ‘‘amber’’ alert requires a viduals with evidence of treatment between the risk factors for agranulocy- repeat FBC test while clozapine can be resistant schizophrenia, clozapine tosis and neutropenia have been extra- should be introduced at the earliest polated primarily from epidemiological continued, and a ‘‘red’’ alert warrants opportunity’’.2 studies, they may be subject to change immediate cessation of clozapine. A severe adverse effect of clozapine as further evidence, from even larger It is important for eligible subjects to that limits its more widespread use is studies, come to light. be registered with the CPMS under the agranulocytosis. Patients who are taking The exact mechanism of clozapine BEN category, so that patients belong- clozapine need to have their full blood induced agranulocytosis is unclear. It ing to certain ethnic groups do not have counts (FBC) monitored regularly, and has been postulated that clozapine is to stop clozapine unnecessarily. This has if the total white cell and/or neutrophil metabolised to a nitrenium ion.8 The great clinical ramifications, as there is counts indicate agranulocytosis, cloza- binding of this ion to neutrophils may no other antipsychotic that has compar- pine prescription must be terminated. result in agranulocytosis. Antineutrophil able efficacy to clozapine in the treat- Among certain ethnic groups, a signifi- antibodies may be involved in mediating ment of resistant schizophrenia. In cant proportion of people have a low agranulocytosis.9 Some human leuco- addition, there is evidence that some baseline neutrophil count. This is called cyte antigen (HLA) alleles, for example ethnic groups, particularly black people, benign ethnic neutropenia (BEN). This the HLA B38 phenotype in Ashkenazi may be less likely, even in the first place, 14 editorial looks at the important issues Jews,10 have been shown to be asso- to be prescribed clozapine. These fac- associated with agranulocytosis and ciated with clozapine induced agranulo- tors may combine to further worsen the BEN in patients receiving clozapine. cytosis. prognosis of an already severely debili- tating illness in this group of patients. As clozapine induced agranulocytosis http://pmj.bmj.com/ CLOZAPINE AND OTHER HAEMATOLOGICAL is an idiosyncratic reaction,8 it is diffi- AGRANULOCYTOSIS ABNORMALITIES cult to predict and to identify high risk Agranulocytosis occurs in about 1% of Clozapine is associated with increased patients. Also, as it is a comparatively patients taking clozapine.34 risk of eosinophilia, particularly in rare phenomenon occurring in less than Neutropenia is seen in about 3%.4 The 11 women. Eosinophilia typically occurs 1% of subjects, the number of reported risk of both agranulocytosis and neu- between weeks 3 and 5 of treatment and cases is not adequate to clearly identify tropenia is highest between 6 weeks and resolves spontaneously without need for specific risk factors; general risk factors 18 weeks after starting clozapine treat- specific treatment. Clozapine is also on September 28, 2021 by guest. Protected copyright. such as increasing age, female sex, etc, ment.4 Hence, in the United Kingdom associated with anaemia, lymphopenia, are not robust enough to change deci- and Ireland, weekly FBC monitoring is leucocytosis, and thrombocytopenia.8 mandatory for the first 18 weeks, after sion making in individual patients. which it is done fortnightly until the Therefore, clinicians should continue to end of the first year, and every four BENIGN ETHNIC NEUTROPENIA remain vigilant against this potentially weeks thereafter. In the USA, FBC is BEN has been defined as ‘‘the occur- fatal side effect of clozapine in all the monitored weekly for the first six rence of neutropenia, defined by nor- patients prescribed this drug, especially months and fortnightly thereafter. mative data in white populations, in in the first few months of treatment. Not all risk factors are the same for individuals of other ethnic groups who are otherwise healthy and who do not ACKNOWLEDGEMENTS agranulocytosis and neutropenia; this 12 implies that there may be distinct have repeated or severe infections’’. Dr Tony Wong, staff grade psychiatrist, South mechanisms for the two disorders. A About 25% to 50% of Africans and some London and Maudsley NHS Trust. low baseline white cell count has been associated with future neutropenia but Table 1 CPMS alert ranges for subjects with BEN (ranges for non-BEN subjects) not agranulocytosis.5 The risk of agra- 9 9 nulocytosis increases with age,36 while Alert colour WCC 610 /l Neutrophils 610 /l 6 that of neutropenia decreases with age. Green .3.0 (.3.5) .1.5 (.2.0) Agranulocytosis is more common in Amber 2.5–3.0 (3.0–3.5) 1.0–1.5 (1.5–2.0) women.3 It is more than twice as Red ,2.5 (,3.0) ,1.0 (,1.5) frequent in Asians as in the white CPMS, Clozaril patient monitoring service; BEN, benign ethnic neutropenia; WCC, white cell count. population.6 Neutropenia, but not www.postgradmedj.com 546 EDITORIAL Postgrad Med J: first published as 10.1136/pgmj.2004.031641 on 2 September 2005. Downloaded from Postgrad Med J 2005;81:545–546. and secondary care. Clinical guideline 1. London: research and implications for drug development. doi: 10.1136/pgmj.2004.031161 NICE, 2002. CNS Drugs 1997;7:139–58. 3 Alvir JM, Lieberman JA, Safferman AZ, et al. 9 Claas FH. Drug-induced agranulocytosis: review Correspondence to: Dr S Rajagopal, South Clozapine-induced agranulocytosis. Incidence of possible mechanisms, and prospects for London and Maudsley NHS Trust, Adamson and risk factors in the United States. N Engl J Med clozapine studies. Psychopharmaclogy (Berl) 1989;99(suppl):S113–17. Centre for Mental Health, St Thomas’s Hospital, 1993;329:162–7. 4 Atkin K, Kendall F, Gould D, et al. Neutropenia 10 Meged S, Stein D, Sitrota P, et al. Human London SE1 7EH, UK; Sundararajan. leukocyte antigen typing, response to [email protected] and agranulocytosis in patients receiving clozapine in the UK and Ireland. Br J Psychiatry neuroleptics, and clozapine-induced Funding: none. 1996;169:483–8. agranulocytosis in jewish Israeli schizophrenic 5 Gillman K. Paradoxical pattern of haematological patients. Int Clin Psychopharmacol Competing interests: none. risk with clozapine. Authors’ reply. Br J Psychiatry 1999;14:305–12. 2000;177:88. 11 Banov MD, Tohen M, Friedberg J. High risk of eosinophilia in women treated with clozapine. 6 Munro J, O’Sullivan D, Andrews C, et al. J Clin Psychiatry 1993;54:466–9. Active monitoring of 12,760 clozapine 12 Haddy TB, Rana SR, Castro O. Benign ethnic REFERENCES recipients in the UK and Ireland. Beyond neutropenia: what is a normal absolute neutrophil pharmacovigilance. Br J Psychiatry 1 Kane J, Honigfeld G, Singer J, et al. count? J Lab Clin Med 1999;133:15–22. 1999;175:576–80. Clozapine for the treatment-resistant 13 Shoenfeld Y, Alkan ML, Asaly A, et al. Benign schizophrenic. A double-blind comparison 7 Alvir JM, Lieberman JA, Safferman AZ. Do white- familial leukopenia and neutropenia in different with chlorpromazine. Arch Gen Psychiatry cell count spikes predict agranulocytosis in ethnic groups. Eur J Haematol 1988;41:273–7. 1988;45:789–96. clozapine recipients? Psychopharmacol Bull 14 Kuno E, Rothbard AB. Racial disparities in 2 National Institute for Clinical Excellence. 1995;31:311–14. antipsychotic prescription patterns for patients Schizophrenia: core interventions in the treatment 8 Pirmohamed M, Park K. Mechanism of clozapine- with schizophrenia. Am J Psychiatry and management of schizophrenia in primary induced agranulocytosis. Current status of 2002;159:567–72. Single subject design generalisability. I would argue that a ....................................................................................... study of this kind cannot provide any reassurance that we can extrapolate the findings to other patients. One could Should the single subject design be say, to other similar patients, but what does similar mean in this context? regarded as a valid alternative to the
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