Clozapine-induced hypotension treated with moclobemide and Bovril

Taylor, David; Reveley, Adrianne; Faivre, Fabien

doi:10.1192/bjp.167.3.409

Cited by 10 publications

(11 citation statements)

References 3 publications

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“…One study 42 with data for one patient used moclobemide 150 mg, a reversible inhibitor of monoamine oxidase A, and Bovril ® 12 g, a tyramine-rich yeast and beef extract, three times daily. This combination was effective in achieving full resolution of symptoms associated with orthostatic hypotension.…”

Section: Resultsmentioning

confidence: 99%

“…Clozapine plasma level was only reported in these two studies (1500 43 and 3912 ng/l). 33 Seven studies with data for nine patients [38][39][40][41][42]44,45 reported orthostatic hypotension on therapeutic doses of clozapine. Time of onset of orthostatic hypotension ranged from 3 to 12 days after commencement of clozapine.…”

Section: Resultsmentioning

confidence: 99%

“…29,32,33,42 Arginine vasopressin. Five studies 29,[31][32][33]42 reported the use of IV vasopressin with data for five patients. Three studies 31,32,42 reported complete resolution of hypotension refractory to fluids and other vasopressors.…”

Section: Wieruszewski Et Al 33mentioning

confidence: 99%

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Treatment strategies for clozapine-induced hypotension: a systematic review

Tanzer

Brouard

Pra

et al. 2022

Therapeutic Advances in Psychopharmacology

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Background: Clozapine is the most effective medication for treatment–refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant. Objectives: Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers. Design: We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence. Data Sources and Methods: PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention. Results: We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use. Conclusion: Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided. Registration: PROSPERO (Registration No. CRD42020191530)

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Treatment strategies for clozapine-induced hypotension: a systematic review

Tanzer

Brouard

Pra

et al. 2022

Therapeutic Advances in Psychopharmacology

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“…If patients complain of dizziness, or the postural drop is over 30 mmHg, titration can be slowed. Patients are encouraged to maintain good hydration, and if symptoms are particularly troubling, the use of moclobemide with Bovril has been reported to be effective in addressing this issue .…”

Section: Methodsmentioning

confidence: 99%

The practical management of refractory schizophrenia - the Maudsley Treatment REview and Assessment Team service approach

Beck

McCutcheon

Bloomfield

et al. 2014

Acta Psychiatr Scand

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The service had increased the number of patients receiving community assessment and initiation of clozapine by five-fold relative to the rate prior to the establishment of the service. The large number of referrals and high attendance rate indicates that there is clinical demand for the model. Systematic evaluation is required to determine the clinical and cost-effectiveness of this model and its potential application to other clinical settings.

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“…In two cases combination of moclobemide (3´150 mg) and tyramine-containing Bovril ® (3´12 g) enhanced hypotension induced by clozapine (231) or central autonomic failure (120). One letter and one retrospective study on 44 patients described a beneficial effect of 300 to 450 mg moclobemide in the prophylactic treatment of migraine with a more marked effect in the migraine with aura (47,161).…”

Section: Miscellaneous Disordersmentioning

confidence: 99%

Moclobemide: Therapeutic Use and Clinical Studies

Bonnet¹

2003

CNS Drug Reviews

205

100

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Moclobemide is a reversible inhibitor of monoamine-oxidase-A (RIMA) and has been extensively evaluated in the treatment of a wide spectrum of depressive disorders and less extensively studied in anxiety disorders. Nearly all meta-analyses and most comparative studies indicated that in the acute management of depression this drug is more efficacious than placebo and as efficacious as tricyclic (or some heterocyclic) antidepressants or selective serotonin reuptake inhibitors (SSRIs). There is a growing evidence that moclobemide is not inferior to other antidepressants in the treatment of subtypes of depression, such as dysthymia, endogenous (unipolar and bipolar), reactive, atypical, agitated, and retarded depression as with other antidepressants limited evidence suggests that moclobemide has consistent long-term efficacy. However, more controlled studies addressing this issue are needed. For patients with bipolar depression the risk of developing mania seems to be not higher with moclobemide than with other antidepressants. The effective therapeutic dose range for moclobemide in most acute phase trials was 300 to 600 mg, divided in 2 to 3 doses. While one controlled trial and one long-term open-label study found moclobemide to be efficacious in social phobia, three controlled trials subsequently revealed either no effect or less robust effects with the tendency of higher doses (600 -900 mg /d) to be more efficacious. Two comparative trials demonstrated moclobemide to be as efficacious as fluoxetine or clomipramine in patients suffering from panic disorder. Placebocontrolled trials in this indication are, however, still lacking.A relationship between the plasma concentration of moclobemide and its therapeutic efficacy is not apparent but a positive correlation with adverse events has been found. Dizziness, nausea and insomnia occurred more frequently on moclobemide than on placebo. Due to negligible anticholinergic and antihistaminic actions, moclobemide has been better tolerated than tri-or heterocyclic antidepressants. Gastrointestinal side effects and, espe-97

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Clozapine-induced hypotension treated with moclobemide and Bovril

Cited by 10 publications

References 3 publications

Treatment strategies for clozapine-induced hypotension: a systematic review

Treatment strategies for clozapine-induced hypotension: a systematic review

The practical management of refractory schizophrenia - the Maudsley Treatment REview and Assessment Team service approach

Moclobemide: Therapeutic Use and Clinical Studies

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