Actions and Spectrum
clozapine acts as an antagonist at dopamine receptors, specifically D2 receptors. By blocking these receptors, it helps to reduce the excessive dopamine activity associated with schizophrenia symptoms.
Frequency defined
1-10%
Syncope (6%)
Sweating (6%)
Fatigue (2%)
Diarrhea (2%)
Urinary abnormalities (2%)
Dry mouth (5-6%)
Leukopenia/neutropenia (3%)
Restlessness (4%)
Akathisia (3%)
Confusion (3%)
Hypertension (4%)
Rash (2%)
Abdominal discomfort/heartburn (4%)
Headache (7-10%)
Seizures (3%)
Rigidity (3%)
Visual disturbances (5%)
Hypokinesia/akinesia (4%)
Agitation (4%)
Disturbed sleep/nightmares (4%)
Tremor (6%)
>10%
Sedation/somnolence (21-46%)
Insomnia (2-20%)
Hypotension (9-13%)
Fever (5-13%)
Nausea (17%)
Dizziness (14-27%)
Dizziness/vertigo (19%)
Vomiting (17%)
Dyspepsia (14%)
Constipation (14-25%)
Tachycardia (17-25%)
Weight gain (4-31%)
Hypersalivation (13-48%)
Post marketing Reports
Musculoskeletal system: Rhabdomyolysis, systemic lupus erythematosus, myasthenic syndrome
Skin: Erythema multiforme, Hypersensitivity reactions, Stevens-Johnson Syndrome, photosensitivity, vasculitis, skin pigmentation disorder
Gastrointestinal system: Acute pancreatitis, dysphagia, megacolon, intestinal obstruction, ischemia, infarction, perforation, salivary gland swelling, colitis, hypersalivation, dry mouth, ulceration
Central nervous system: Tardive dyskinesia, neuroleptic malignant syndrome, restless leg syndrome, Delirium, EEG abnormal, myoclonus, paresthesia, possible cataplexy, status epilepticus, obsessive compulsive symptoms
Hepatobiliary: Hepatic fibrosis, hepatic cirrhosis, liver injury, hepatotoxicity, hepatic steatosis, hepatic necrosis, liver failure
Urogenital: Renal failure, priapism, retrograde ejaculation, nocturnal enuresis, acute interstitial nephritis
Hemic and lymphatic system: DVT, ESR, sepsis, angioedema, leukocytoclastic vasculitis, eosinophilia, pulmonary embolism, thrombocytosis, thrombocytopenia
Vision disorders: Narrow-angle glaucoma
Cardiovascular: Atrial or ventricular tachycardia or fibrillation, periorbital edema, myocardial infarction, mitral valve incompetence, bradycardia, cardiomyopathy, myocarditis, cardiac arrest, QT prolongation, hypertension
Immune system disorders: Angioedema, leukocytoclastic vasculitis
Miscellaneous: CPK elevation, weight loss, polyserositis, hyperuricemia, hyponatremia
Endocrine system: Pseudo pheochromocytoma
Respiratory system: Pneumonia, lower respiratory tract infection (LRTI), Aspiration, pleural effusion
Black Box Warning
clozapine treatment has been associated with a significant risk of agranulocytosis, which is a severe decrease in the number of white blood cells.
clozapine has a potential to lower the seizure threshold. Seizures have been reported in patients taking clozapine, and caution should be exercised in individuals with a history of seizures.
Cases of myocarditis (inflammation of the heart muscle) and cardiomyopathy (disease of the heart muscle) have been reported with clozapine use.
Contraindication/Caution:
Contraindication:
- Individuals with past history of hypersensitivity reaction to clozapine or any of its components should not use this medication.
Caution:
- Caution should be taken in patients who are prone to hypotension or who have conditions that may be exacerbated by low blood pressure.
- Caution should be taken in patients with severe renal impairment due to potential changes in drug clearance.
- Caution should be exercised in patients with a history of heart conditions, those experiencing symptoms of heart problems.
Pregnancy consideration:
Pregnancy category: N/A
Lactation: It present in human milk
Pregnancy Categories:
Category A: well-controlled and Satisfactory studies show no risk to the fetus in the first or later trimester.
Category B: there was no evidence of risk to the fetus in animal studies, and there were not enough studies on pregnant women.
Category C: there was evidence of risk of adverse effects in animal reproduction studies, and no adequate evidence in human studies must take care of potential risks in pregnant women.
Category D: adequate data with sufficient evidence of human fetal risk from various platforms, but despite the potential risk, and used only in emergency cases for potential benefits.
Category X: Drugs listed in this category outweigh the risks over benefits. Hence these categories of drugs need to be avoided by pregnant women.
Category N: There is no data available for the drug under this category.
Pharmacology
It exhibits weak D2- and D1-receptor blocking activity, but it has important nor adrenolytic, anticholinergic, antihistaminic, and arousal reaction suppressing actions. It also has antiserotoninergic properties.
The significant effects in controlling behavioral and mental symptoms with low incidence of EPS are attributed to affinity for mesolimbic dopamine D4 receptors.
Pharmacodynamics
clozapine exhibits antagonistic activity at alpha-1 adrenergic receptors. Clozapine acts as an antagonist for histamine H1 receptors.
Pharmacokinetics
Absorption
clozapine is absorbed after oral administration, with peak plasma concentrations reached within 1.5 to 2.5 hours.
Distribution
clozapine has a high level of protein binding of 97% to albumin and alpha-1-acid glycoprotein.
Metabolism
clozapine undergoes metabolism in the liver, through the cytochrome P450 (CYP) enzyme system.
Elimination and excretion
clozapine and its metabolites are excreted in the urine. The elimination half-life of clozapine ranges from 8 to 12 hours.