Therapeutic drug

Monitoring:
TDM of Clozapine
and Other Anti-
psychotics

28th November 2014

FRCPath Lecture
Lewis Couchman (lewis.couchman@nhs.net)
 Kingspath Clozapine
Introduction -I Assay Service
– HPLC-UV (or LC-MS/MS) clozapine/norclozapine assay
– 0.5 mL plasma/serum (‘trough sample’)
– Turn-around 2 working days unless problems e.g. lipaemic sample
- Analytical development coming soon - same-day reporting
– Results available immediately on-line once authorised
- Previous results also available on-line
- Cyberlab pilot-testing
– Urgent results faxed/telephoned
– Interpretation based upon 200,000+ real TDM samples
– Cost: £25/test
- Sample mailing kits provided (CPMS & DMS patients)
- Can provide packing for hazardous samples (e.g. Hep C)
 Introduction - II

– LC-MS atypical antipsychotic assay service

– Olanzapine, risperidone, quetiapine, aripiprazole, amisulpride,
sulpiride
– 0.5 mL plasma/serum (‘trough sample’)
– Turn-around 2-4 working days
– Results available immediately on-line once authorised - Urgent results
faxed/telephoned
– Previous results also available on-line
– Cost: £35/test
– BNF Zyprexa cost (1 yr, 20 mg/d) £2,065 (Sept 2010)
 16
,0
22
Clozapine Assays 1993-2010 (n = 166,102)

94
,1
20 4 09
6 20
,7
19
63
,6
15 07
16 20
,9
14
97
,1
13 1 05
9 20
,6
13
74
,1
12 6 03
60 20
9,
3
63
8, 01
8
36 20
6,
6
24
4, 99
2
42 19
2,
2
76
1, 97
1 19
91
8
43 95
67 19
34
93
19
24,000

21,000

18,000

15,000

12,000

9,000

6,000

3,000

0
No of samples
Clozapine Assays/Patient 1993-2007
(N = 104,127)

7
10,000

60
9,
9,000

8,000

7,000
No of patients

6,000 3
14
5,

5,000

4,000
1
10
3,

3,000
5
13

0
2,

57

2,000 6

9
1,

14

01
1,

1,
81

7
1,000
57

2
48

41
37

37

33

2
0

-
0

51 0

1-
00
1

9
10
15

-2

-5

10
-1
16

21
No of samples
 TDM of Antipsychotics

– Conventional
- Chlorpromazine many (unstable) metabolites, some probably
pharmacologically active
- Haloperidol potent drug; haloperidol/reduced haloperidol assay not
widely available
- (Sulpiride)

– Atypical (second generation)

- Clozapine
- Olanzapine
- Amisulpride, aripiprazole, quetiapine, risperidone
 TDM of Clozapine/Norclozapine

– Assess adherence
– ‘Trough’ plasma concentration/clinical effect:
< 0.35 mg/L: Possible reason for poor/no response
0.35–0.6 mg/L: Best response/minimal side effects
0.6–1 mg/L: Dose reduction (may lose response)?
> 1 mg/L: Dose reduction/valproate cover?
> 2 mg/L: URGENT dose reduction/valproate cover?
– Investigate ADRs, sudden deaths
Bioequivalence of Clozapine Brands

Ratio%: Brand to Clozaril 300

250

200

150

100

50

0
Denzapine Zaponex Denzapine Zaponex

clozapine
Clozapine nor-clozapine
Norclozapine
 Problems with using Clozapine

– Not always effective

– Clozapine has to be given orally – problems with
adherence (and constipation)
– Bone marrow toxicity in 1–2 % patients – mandatory
blood monitoring
– Other rare idiosyncratic effects (myocarditis,
cardiomyopathy, fatal arrythmia, hepatotoxicity)
– Dose-related toxicity (hypersalivation, drowsiness,
convulsions, etc.)
 Clozapine Pk - Practicalities

– Up to 50 x inter-individual variation in metabolic rate

– Very few serious drug-drug interactions
- Fluvoxamine, some antibiotics (erythromycin,
ciprofloxacin), carbamazepine, phenytoin
– Clozapine clearance dose dependent (first pass
saturable?)
- Basis of cautious dose titration
- Basis of clozapine accumulation in some patients
– Smoking habit big effect (dose requirement ± 50 %
smokers/non-smokers)
 Norclozapine (N-Desmethylclozapine)

– Main plasma clozapine metabolite

– Has longer plasma half-life than clozapine
– More may accumulate in tissue (possibly even in brain)
than clozapine
– May have antipsychotic activity (has similar in vitro
receptor binding & white cell toxicity to clozapine)
– Plasma C:NC ratio (early samples sent to us) averaged
1.33 across dose range (50–900+ mg/d)
- C:NC ratio as important as dose and smoking status in
determining plasma clozapine
 Clozapine:Norclozapine Ratio vs. Dose
(median, 10th and 90th percentiles; N = 20,145)

2.5
Clozapine:norclozapine ratio

1.5

0.5

0
50- (727) 151- 251- 351- 451- 551- 651- 751- 851-
(1934) (4060) (4638) (3369) (2567) (1527) (779) (544)

Dose (mg/d)
 Prediction of Plasma Clozapine

– Expected clozapine concentration

Log 10 [ Clozapine ] = 0 . 811 Log 10 ( dose ) + 0 . 322 ( MR ) + 69 . 42 x10 − 3 ( sex ) + 2 . 263 x10 − 3 ( age )

+ 1.976 x10 −3 ( weight ) − 0.171( smoking ) − 3.180

– Predicted plasma clozapine changed by:

+ 48 % in non-smokers
+ 17 % in females
± 8 % for every 0.1 change in MR (base 1.32)
± 4 % for every 5 yr of age (base 40 yr)
± 5 % for every 10 kg body weight (base 80
kg)
 Predicted vs. Actual Plasma Clozapine

– Regression analysis explained 48 % of variation. BUT

clinical samples
– Rest of variation:
– Adherence
– MR clozapine concentration (and dose?) dependent
– Other drugs
– Smoking intensity?
– Constipation?
– Some not trough samples
– Wrong information
 Why Measure Norclozapine?

– Ensure selective assay used (important for PM work)

– Helps assess adherence (less short-term change than
clozapine)
– C:NC ratio (inbuilt QA)
< 0.5 suggests poor adherence in preceding day(s)
> 3 suggests not ‘trough’ sample (or inhibition of N-
demethylation)
BUT ratio saturable (normally more obvious if plasma
clozapine > 1 mg/L)
 Median Clozapine:Norclozapine Ratio
and Plasma [Clozapine]

Plasma clozapine (mg/L) Clozapine:norclozapine ratio

<0.35 1.25
0.35–0.59 1.55
0.60–0.99 1.78
> 1.00 2.08
 Median Clozapine:Norclozapine Ratio
vs. Dose and Plasma [Clozapine]
Clozapine <0.35 mg/L Clozapine >0.35 mg/L
Clozapine >0.60 mg/L Clozapine >1.0 mg/L
3

2.5
% (N =
2
85,958)
C:NC ratio

9
1.5 20
30
1 42

0.5

0
50- 151- 251- 351- 451- 551- 651- 751- 851-
(2632) (8338) (18794) (20677) (14504) (10509) (5507) (3129) (1868)
Prescribed dose (mg/d)
 Clozapine Accumulation: 2002/3
Patient: 58, F; 30-Oct: Tired ++, postural hypotension

Clozapine Norclozapine Dose

Stop
6 700
[Analyte] (mg/L)

5 600

Dose (mg/d)
4 500
400
3 Re-start
300
2 200
1 100
0 0

24 n
12 n
20 ov
26 ov
30 ov
ov

28 ec
10 ec
13 ec
30 y

ar
11 ct
a

a
a
-O

-M
-N
-N
-N
-N

-D
-D
-M

-J
-J
5-
31
 Summary TDM Data 1993-2007
(N = 104,127 from 26,796 patients)

Plasma concentration (mg/L)

<0.01 <0.35 0.35– 0.6– 1.00– 2.0–

Clozapine N 1,534* 42,653 30,535 20,667 8,277 461

% 1.5 41.0 29.3 19.9 8.0 0.4

* Samples from 1259 patients; in 247 of these samples norclozapine

detected at low concentration (0.05 mg/L or less)
 Inquest Told of Death at Hospital

Oxford Mail Tuesday 13 January 2009

– A patient found collapsed in a hospital bathroom may
have taken a fellow patient’s drugs, an inquest heard
today
– Tests after his death found a potentially fatal amount
of clozapine, a drug he had never been prescribed
– Post mortem femoral blood clozapine and
norclozapine concentrations were 0.48 and 0.20
mg/L, respectively
– A fellow patient admitted later on the day he died that
he had shared his drugs with him
 No. of samples

0
20
40
60
80
100
120
140
160
180
<5
50 0

22
-1
10 00

76
1-
1
15 5 0

49
1-
20
(N = 998)

20 0

87
1-
2
25 5 0

71
1-
3
30 0 0
1-
154

3
35 5 0
94

1-
4
40 0 0
1-
141

45
45 0
80

1-
5
50 0 0
63

1-
5
55 5 0
32

1-
6
60 0 0
66

1-
Prescribed dose (mg/d)
65
65 0
17

1-
7
70 0 0
17

1-
7
No Clozapine Detected: Dose

75 5 0
10

1-
8
80 0 0
12

1-
85
0
1

85
1-
6
 Clozapine ≥ 2 mg/L 1993-2007
(N = 461, 379 patients)

2.5
[Norclozapine] (mg/L)

1.5

0.5

0
2 2.5 3 3.5 4 4.5 5
[Clozapine] (mg/L)
8 samples (7 patients) co-prescribed omeprazole, 7 (4 patients) co-prescribed
fluvoxamine, 1 sample from patient co-prescribed erythromycin)
 Clozapine TDM 1993-2003: Summary

Plasma clozapine (mg/L)

<0.01 <0.35 0.35– 0.60– 1.0– 2.0–
M (41,878 samples, N 679* 18,855 12,050 7,434 2,745 115
12,228 patients) % 1.6 45.0 28.8 17.8 6.6 0.3
F (16,294 samples, N 214** 5,814 4,598 3,702 1,835 131
5,143 patients) % 1.3 35.7 28.2 22.7 11.3 0.8
* 566 patients ** 178 patients
 Clozapine TDM Data 1993-2003
(N = 58,497)

Where information available:

– Males significantly younger (p < 0.01): mean age
males 36 yr, females 39 yr
– Males significantly heaver (p < 0.01): mean male
weight 86 kg, female 79 kg
– Smoking habit: 71 % of males smokers, 59 % of
females
 Schizophrenia, Smoking and Clozapine

– People with schizophrenia commonly smoke (± 85 %)

– Thought to have some antipsychotic effect
– Smokers increased risk of premature death
– People on clozapine increased risk of premature death
– People on clozapine may smoke more if income
increases (discharged from hospital: DLA, backdated
benefit payments): possibly increased suicide risk, etc.
– Some manage/have to stop smoking when mental state
improves/in hospital: risk of clozapine toxicity!
– Even risk of clozapine toxicity if bad chest infection!
 Clozapine 1993-2003: Dose
(Median, 10–90th percentile, N = 32,082)

Male Female
800 17,620
5,576 5,996
700
Prescribed Dose (mg/d)

3,290
600
500
400
300
200
100
0
Smoker Non Smoker
(p < 0.01) (p < 0.01)
Clozapine 1993-2003: Plasma Clozapine
(Median, 10–90th percentile, N = 34,530)

Male Female
1.4
3,930
1.2
7,195
[Clozapine] (mg/L)

1 5,662
17,742
0.8

0.6

0.4

0.2

0
Smoker Non Smoker
(p < 0.01) (p < 0.01)
 C:NC Ratio (median, 10th/90th percentiles)
vs. [Cloz] and gender

Male (N= 42,406) Female (N= 16,657)

3.5
Clozapine: norclozapine ratio

2.5

1.5

0.5

0
0.01- 0.35- 0.60- 1.0-
[Clozapine] (mg/L)
 Male vs. Female Pharmacokinetic
Differences
Pharmacokinetic Comments
factor
Gastric emptying Slower in females – slower transit, therefore higher
incidence of clozapine-induced paralytic ileus
Blood volume Lower in females
% body fat Relative to body weight, increased in females – larger
volume of distribution (V) for lipophilic compounds such
as clozapine
CYP 1A2 activity Reduced in females – increased clozapine/norclozapine
ratio
P-Glycoprotein Reduced in females – drugs remain in hepatocytes longer
activity and are more extensively metabolised
GFR Reduced in females – slower clearance
 Plasma Clozapine/Norclozapine vs. Dose
(Median, 10th & 90th percentiles, mg/L; N = 85,958)

Dose (mg/d) N Clozapine Norclozapine

50-150 2,632 0.20 (0.06-0.55) 0.13 (0.05-0.28)

151-250 8,338 0.30 (0.09-0.72) 0.19 (0.08-0.38)
251-350 18,794 0.34 (0.13-0.79) 0.23 (0.10-0.46)
351-450 20,677 0.40 (0.16-0.90) 0.27 (0.12-0.53)
451-550 14,504 0.45 (0.19-1.00) 0.31 (0.15-0.60)
551-650 10,509 0.50 (0.22-1.08) 0.35 (0.16-0.67)
651-750 5,507 0.54 (0.23-1.16) 0.37 (0.18-0.72)
751-850 3,129 0.57 (0.25-1.25) 0.39 (0.19-0.80)
851- 1,868 0.55 (0.25-1.24) 0.41 (0.19-0.84)
 Plasma Clozapine/Norclozapine vs. Dose
(Median, 10th & 90th percentiles, mg/L; N = 85,958)

Clozapine Norclozapine Target for clozapine

1.3
1.2
1.1
1
0.9
[Analyte] (mg/L)

0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
50- 151- 251- 351- 451- 551- 651- 751- 851-
(2632) (8338) (18794) (20677) (14504) (10509) (5507) (3129) (1868)

Prescribed dose (mg/d)

 The young male smoker with TRS

Clozapine Norclozapine Dose Target for clozapine

0.45 800
0.40 700
0.35
[Analyte] (mg/L)

600

Dose (mg/d)
0.30
500
0.25
400
0.20
300
0.15
0.10 200
0.05 100
0.00 0
3

4
/0

/0

/0

/0

/0

/0

/0

/0

/0

/0

/0
06

07

08

10

11

12

01

03

04

05

06
 [Analyte] (mg/L)
06
12.04
.

0
0.5
1
1.5
2
19.04 201 2.5
.
26.04 2010
.
04.04 2010
.
10.05 2010
.
17.05 2010
.
24.05 2010
.
01.05 2010
.
07.06 2010
.
14.06 2010
.
21.06 2010
.
28.06 2010
.
05.06 2010
Clozapine

. 0
12.07 201
.
19.07 2010
.
26.07 2010
.
02.07 2010
.
23.08 2010
.
20.08 2010
.
18.09 2010
.
Norclozapine

15.10 2010
.
13.11 2010
.
10.12 2010
.
07.01 2010
.
27.02 2010
Dose
A female non-smoker with TRS
Also prescribed aripiprazole, C:NC median 3.0 (range 2.5–3.9)

.0 .20 1
6. 1
20 1
11
0
100
200
300
400
500
600
700

Dose (mg/d)
Clozapine: Common Questions

– Why does plasma clozapine vary @ constant dose?

- Adherence (if suspension shake the bottle!)
- Sample timing wrt last dose (has the norclozapine changed
too?)
- Smoking habit/intensity?
- Gastrointestinal motility?
- Metabolism saturated?
- Other drugs?
– Why has the response diminished?
- Adherence (see above)
- Is clozapine psychotic at higher plasma concentrations (>1
mg/L), or can the response decrease with time??
 [Analyte] (mg/L)
29
/

0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
5/1/ 0
13 2/ 2
30/2/0 2
22 /7 02
29/10/ 02
Clozapine

26/10 /02
18/11 /02
/
1412 //02
28/1/ 02
12/1/ 03
26/2/ 03
10/2/ 03
25/3/ 03
28/3/ 03
13/4/ 03
/5 03
3 /
Norclozapine

24/6/ 03
/ 0
8/6/ 03
7 3
228/9/0 3
/ /
1212 0 3
11/7//03
14/2/ 04
13 /9 05
Dose

24/10/ 05
28/10 /05
/ /
9/11 /05
22 12 05
/1 / 0
3/ 2 /05
6/1/0 5
24 2/ 6
/4 0 6
/0
6
0
100
200
300
400
500
600
700
Why TDM in this patient (M, 27)?

Dose (mg/d)
Target for clozapine
 Co-prescribed Medication: 1993-2003

Number of other medications mentioned Frequency

0 22,773
1 7,767
2 6,348
3 4,277
4 2,541
5 1,471
6 681
7 348
8 180
9 125
10-16 150
Total number of samples 46,661
 [Analyte] (mg/L)
18
/1

0.0
0.5
1.0
1.5
2.0
2.5
11 2 /0
/2 1
6/ / 02
22 3/0
/ 2
Clozapine

24 4/ 0
/ 2
17 6/ 0
/ 2
30 9/ 0
15 /9/ 2
/ 0
25 10 / 2
/1 02
20 1 /0
/ 2
26 1/ 0
/3 3
9/ / 03
7
Norclozapine

8/ /0 3
30 9/
/1 0 3
24 0 /0
/ 3
22 2/ 0
/ 4
30 6/ 0
/ 4
24 6/ 0
Dose

11 /9/ 4
/1 04
1
2/ /04
16 6/0
High-dose Clozapine (47, M)

/ 5
21 6/ 0
/6 5
1/ / 05
7/
05
0
100
200
300
400
500
600
700
800
900
1000

Dose (mg/d)
Target for clozapine
 Clozapine TDM: The Future

– C/NC assay now easy (HPLC)

- Results-on-line reports data in clinically-useful time-
frame
- Electronic requesting (Cyberlab)
- Same-day reporting – new assay approach

– Interpretation may not be straightforward

- Use NC as well C to aid interpretation?
- Constipation
- Further data analysis underway (N = 100,000+): sex,
smoking intensity, caffeine, drug interactions, ADRs, etc.
Further Reading (I)

– Flanagan RJ. A practical approach to clozapine therapeutic drug

monitoring. CMHP Bulletin 2010; Issue 2 (June): 4-5.
– Flanagan RJ. Clozapine therapeutic drug monitoring. Why is it
important to monitor clozapine doses effectively? Br J Clin
Pharm 2011; 3: 18-20.
– MacCall CA, et al. Clozapine: More than 900 mg/d may be
needed. J Psychopharmacol 2008 23; 206-10
– Rostami-Hodjegan A, et al. Influence of dose, cigarette smok-ing,
age, sex and metabolic activity on plasma clozapine
concentrations. J Clin Psychopharmacol 2004; 24: 70-78
– Couchman L, et al. Plasma clozapine, norclozapine, and the
clozapine:norclozapine ratio in relation to prescribed dose and
other factors: Data from a Therapeutic Drug Monitoring service,
1993-2007. Ther Drug Monit 2010; 32: 438-47
 Further Reading (II)

– Flanagan RJ, Ball RY. Gastrointestinal hypomotility: An under-

recognised life-threatening adverse effect of clozapine. Forensic Sci
Int 2010
– Couchman L, et al. Plasma clozapine and norclozapine in patients
prescribed different brands of clozapine (Clozaril® , Denzapine®,
and Zaponex®). Ther Drug Monit 2010; 32: 624-7
– Patel MX, et al. Plasma olanzapine in relation to prescribed dose
and other factors: Data from a Therapeutic Drug Monitoring service,
1999-2009. J Clin Psychopharmacol 2011; 31: 411-7.
– Bowskill S, et al. Plasma clozapine and norclozapine in relation to
prescribed dose and other factors in patients aged 65 years and
over: Data from a Therapeutic Drug Monitoring service, 1996-2010.
Hum Psychopharmacol Clin Exp 2012; 27: 277-83.
Further Reading (III)

– Bowskill S, et al. Risperidone and total 9-hydroxyrisperidone in

relation to prescribed dose and other factors: Data from a
therapeutic drug monitoring service, 2002-2010. Ther Drug Monit
2012; 34: 349-55.
– Couchman L, et al. Plasma clozapine and norclozapine in
relation to prescribed dose and other factors in patients aged
<18 years: Data from a Therapeutic Drug Monitoring service,
1994-2010. Early Interven Psychiatr 2012 (In press)
– Fisher D, et al. Plasma concentrations of quetiapine, N-des-
alkylquetiapine, O-desalkylquetiapine, 7-hydroxyquetiapine and
quetiapine sulfoxide in relation to quetiapine dose, formulation
and other factors. Ther Drug Monit 2012; 34: 415-21.
– Bowskill SVJ, et al. Plasma amisulpride in relation to prescribed
dose, clozapine augmentation, and other factors: data from a
therapeutic drug monitoring service, 2002–2010. Hum
Psychopharmacol Clin Exp 2012 (in press).
Thank You!

Any Questions?

Lewis Couchman
Toxicology Unit, King’s College
Hospital
Denmark Hill
London
SE5 9RS

lewis.couchman@nhs.net
www.viapath.co.uk