Schizophrenia Clinical Trial
Official title:
Treatment Strategy for Refractory Schizophrenia: Drug Interaction Between Clozapine and Fluvoxamine
Clozapine has been virtually the only psychopharmacological choice in patients with
schizophrenia who either did not response to typical neuroleptics or experienced severe
extrapyramidal side effects and consequently did not tolerate this medication. There are
patients who do not respond to clozapine, and the need to treat these severely ill patients
frequently compels clinicians to adopt therapeutic innovations that lack a sound empirical
basis. One strategy is the combination of various other somatic treatments with clozapine.
Recently, the investigators conduct a preliminary open trial to evaluate the safety and
efficacy of fluvoxamine coadministration with clozapine in refractory schizophrenic
patients. The combined treatment is well tolerated, and clinical improvement is observed in
our patients. And the concomitant fluvoxamine could attenuate the clozapine-induced weight
gain and metabolic disturbance. However, the effects of fluvoxamine on the safety and
therapeutic efficacy of clozapine need to be further clarified in double-blind study.
Background Schizophrenia is one of the most severe mental illnesses. The prevalence of
schizophrenia has been variously reported as ranging from 1 to 1.5 percent. More than 50% of
patients can be described as having a poor outcome, with repeated hospitalizations,
exacerbations of symptoms, episodes of major mood disorders, and suicide attempts.
Schizophrenia is costly in medical care, treatment and rehabilitation, and reduced or lost
productivity. Therefore, the development of effective treatment for schizophrenic patients
is an important issue.
The classical antipsychotic drugs are the dopamine receptor antagonists, which are effective
in the treatment of schizophrenia, particularly of the positive symptoms. Even with
treatment of typical antipsychotics, about 50% of schizophrenic patients lead severely
debilitated lives. Second, the classical antipsychotic drugs are associated with annoying
and serious adverse effects. Clozapine has been virtually the only psychopharmacological
choice in patients with schizophrenia who either did not response to typical neuroleptics or
experienced severe extrapyramidal side effects and consequently did not tolerate this
medication. There are patients who do not respond to clozapine, and the need to treat these
severely ill patients frequently compels clinicians to adopt therapeutic innovations that
lack a sound empirical basis. One strategy is the combination of various other somatic
treatments with clozapine.
Recently, the investigators conduct a preliminary open trial to evaluate the safety and
efficacy of fluvoxamine coadministration with clozapine in refractory schizophrenic
patients. The mean plasma clozapine levels obtained by clozapine 100 mg/day plus fluvoxamine
50 mg/day is close to that produced by 300-mg/day clozapine monotherapy in one of our
previous studies. The combined treatment is well tolerated, and clinical improvement is
observed in our patients. And the concomitant fluvoxamine could attenuate the
clozapine-induced weight gain and metabolic disturbance. However, the effects of fluvoxamine
on the safety and therapeutic efficacy of clozapine need to be further clarified in
double-blind study.
Methods This study is a three-year proposal. Sixty treatment-resistant schizophrenic
inpatients will participate in this project. The subjects will be randomized to one of two
parallel groups: clozapine monotherapy and clozapine plus fluvoxamine treatment. The
double-blind active treatment will consist of two periods.
The measures of clinical efficacy will be the Positive And Negative Syndrome Scale, Clinical
Global Impression, and Nurses'Observation Scale for Inpatient Evaluation. The measures of
side effects will be the Extrapyramidal Symptom Rating Scale and the UKU Side Effect Rating
Scale. Fasting serum samples are collected to determine the lipid profile (total
cholesterol, triglycerides, HDL, and LDL), glucose level, and insulin level. Plasma levels
of clozapine, norclozapine, and clozapine N-oxide will be determined by high performance
liquid chromatography with ultraviolet detection.
The following results are expected:
1. In treatment-resistant schizophrenic patients, global antipsychotic effect of clozapine
plus fluvoxamine treatment is superior to clozapine monotherapy.
2. Clozapine plus fluvoxamine treatment has less adverse effects than clozapine
monotherapy.
3. The effect of clozapine plus fluvoxamine treatment on body weight and metabolic
disturbances is superior to clozapine monotherapy.
4. Steady-state plasma levels of clozapine and its metabolites account for a proportion of
variance of clinical effects.
;
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator, Outcomes Assessor), Primary Purpose: Treatment
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