Asia Pacific Journal of Medical Toxicology

Successful Management of Acute Anti psychotic Poisoning Induced Multi-Organs Toxicities -A Case Report and Review of Literature

Document Type : Case Report

Authors

Manal Abdelaziz Hassan 1
Fatma Mohamed Magdy Badreldine 2
Rasha Mohamed Abayazeed 3
Rasha Ismail Abdelrasol Khedr 4
Eman Mohamed Saleh 5

1 faculty of medicine Alexandria University

2 Departments of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Champollion Street, El- Khartoum Square, Azarita Medical Campus, Alexandria, Egypt

3 Cardiology and angiology department, faculty of medicine, Alexandria University

4 Forensic medicine and clinical toxicology department, faculty of medicine, Alexandria University

5 Staff member at forensic medicine and clinical toxicology department faculty of medicine, Alexandria University

https://doi.org/10.22038/apjmt.2024.80297.1459
Abstract
Introduction: Atypical antipsychotics were usually used in management of many psychiatric disorders. Moreover, suicidal attempts by antipsychotic agents are not rare in clinical practice. Therefore toxicologists should be aware of the early detection and management of those patients. Clozapine is one of the most commonly used antipsychotic drugs due to its well-known efficacy.
Case presentation: this is a case report of a young previously healthy male patient who committed suicide by ingestion of 1000 mg of the atypical antipsychotic drug clozapine. The case highlights the development of severe disturbed level of consciousness, extrapyramidal adverse effects, prolonged QTc with positive troponin, hypokalemia, hyperglycemia, transient hypertension, and elevated liver transaminases. Discussion: The proper treatment initiation of acute antipsychotic poisoning should be based on the patient's clinical assessment. Early central nervous system and cardiovascular support are the core treatment element. However, the case reported uncommon electrolyte and hepatic disturbances which require early detection and monitoring.
Conclusion: Atypical antipsychotics are not usually a safe treatment option for psychiatric diseases. Acute clozapine poisoning is a serious condition in which early resuscitation is essential for good prognosis. Serious cardiac and metabolic adverse effects should be considered, early investigated and properly monitored. Serum drug level might not be helpful prognostic indicator for acute antipsychotic poisoning.

Keywords

Atypical Antipsychotics
Clozapine
Clozapine Level
Successful Management
Subjects
  1. Crossley NA, Constante M, McGuire P, Power P. Efficacy of atypical v. typical antipsychotics in the treatment of early psychosis: meta-analysis. Br J Psychiatry. 2010;196(6):434-9.
  2. Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs. 2012;26(7):601-11.
  3. Hutton P, Di Rienzo F, Turkington D, Spencer H, Taylor P. Suicidal ideation in people with psychosis not taking antipsychotic medication: Do negative appraisals and negative metacognitive beliefs mediate the effect of symptoms? Schizophr Bull. 2019;45(1):37-47.
  4. Seeman P. Atypical antipsychotics: mechanism of action. Can J Psychiatry. 2002;47(1):27-38.
  5. Hirsch L, Yang J, Bresee L, Jette N, Patten S, Pringsheim T. Second-generation antipsychotics and metabolic side effects: a systematic review of population-based studies. Drug Saf. 2017;40:771-81.
  6. Muench J, Hamer AM. Adverse effects of antipsychotic medications. Am Fam Physician. 2010;81(5):617-22.
  7. Gupta S, Khastgir U, Croft M, Roshny S. Management of clozapine-induced sialorrhoea. BJPsych Adv. 2019;26(2):106-8.
  8. Kurz M, Hummer M, Oberbauer H, Fleischhacker WW. Extrapyramidal side effects of clozapine and haloperidol. Psychopharmacology (Berl). 1995;118(1):52-6.
  9. Lyall M, Pryor A, Murray K. Clozapine and speech dysfluency: two case reports. Psychol Bull. 2018;31(1):16-8.
  10. Li XQ, Tang XR, Li LL. Antipsychotics cardiotoxicity: What's known and what's next. World J Psychiatry. 2021;11(10):736-53.
  11. Coulter D, Director I. Atypical antipsychotics may cause hypertension. Prescriber Update. 2003;24(1):4.
  12. Alves BB, Oliveira GdP, Moreira Neto MG, Fiorilli RB, Cestário EdES. Use of atypical antipsychotics and risk of hypertension: A case report and review literature. SAGE Open Med Case Rep. 2019;7:2050313X19841825.
  13. Wu CS, Tsai YT, Tsai HJ. Antipsychotic drugs and the risk of ventricular arrhythmia and/or sudden cardiac death: a nation‐wide case‐crossover study. J Am Heart Assoc. 2015;4(2):e001568.
  14. Ponte M, Keller G, Girolamo G. Mechanisms of drug induced QT interval prolongation. Curr Drug Saf. 2009;5(1):44-53.
  15. Hoorn EJ, van der Poel MF. Hypokalemic hypertension related to clozapine: a case report. J Clin Psychopharmacol. 2014;34(3):390-2.
  16. Gaze DC, Collinson PO. Cardiac troponins as biomarkers of drug- and toxin-induced cardiac toxicity and cardioprotection. Expert Opin Drug Metab Toxicol. 2005;1(4):715-25.
  17. Klein N, Barnett L, Guirgis H, Stearns WH. Transient Clozapine-induced Myocarditis Without Discontinuation of Medication: A Series of 2 Patients. J Psychiatr Pract. 2022;28(2):170-5.
  18. Whittaker D, Lam D, Murray K, Williams T, Porwal K, Gordon T, et al. Echocardiography is Limited in Predicting Myocarditis in Patients Receiving Clozapine Therapy. Heart Lung Circ. 2022;31:S159.
  19. Yuen JWY, Kim DD, Procyshyn RM, Panenka WJ, Honer WG, Barr AM. A Focused Review of the Metabolic Side-Effects of Clozapine. Front Endocrinol (Lausanne). 2021;12:609240.
  20. Kumar P, Mishra DK, Mishra N, Ahuja S, Raghuvanshi G, Niranjan V. Acute onset clozapine-induced hyperglycaemia: A case report. Gen Psychiatr. 2019;32(2):e100045.
  21. Wu Chou AI, Lu ML, Shen WW. Hepatotoxicity induced by clozapine: a case report and review of literature. Neuropsychiatr Dis Treat. 2014;10:1585-7.
  22. Lopes L, Remelhe M, Estevinho MM, Venâncio Â, Pereira S. Asymptomatic hepatitis as a late side effect of clozapine: A case report. Psychiatry Res Case Rep. 2023;2(1):100107.
  23. Lee J, Kim M-G, Jeong H-C, Shin K-H. Physiologically-based pharmacokinetic model for clozapine in Korean patients with schizophrenia. Transl Clin Pharmacol. 2021;29(1):33-44.
  24. Ibrahim N, El-Masry M, Abd El-Fatah A. Study of the Correlation between clozapine levels and clinical findings in acutely intoxicated patients admitted to Poison Control Center-Ain Shams University Hospitals: 6 months (A prospective Study). Ain Shams J Forensic Med Clin Toxicol. 2022;38(1):11-8.
  25. Thanacoody R. Principles of assessment and diagnosis of the poisoned patient. Medicine. 2020;48(3):156-9.

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