Dratcu Luiz, Grandison Alistair, McKay Gavin, Bamidele Adekunle, Vasudevan Vinodini
York Clinic, Guy's Hospital, Southwark Division of Inpatient Psychiatry, South London and Maudsley NHS Trust, London, United Kingdom.
Am J Ther. 2007 May-Jun;14(3):314-8. doi: 10.1097/01.pap.0000249958.96498.ce.
More than 30% of patients with psychotic disorders who are refractory to antipsychotic treatment also fail to respond to clozapine. Despite the high prevalence of smoking and caffeine use in the psychiatric population, these habits are usually overlooked as factors contributing to antipsychotic treatment failure. We describe 2 male patients with severe treatment-resistant psychosis, one with schizophrenia and the other with bipolar affective disorder-both of whom smoked heavily, and the latter also consumed enormous amounts of caffeine-whose symptoms were refractory to clozapine. Both patients experienced a major, sustained amelioration of their psychotic symptoms when clozapine treatment was recommenced under supervision in the inpatient setting and the pharmacological interactions between clozapine, smoking, and caffeine were considered. Therapeutic strategies included gradual increases in daily doses of clozapine, monitoring clozapine plasma levels, using single daily doses of clozapine at night, and augmenting clozapine treatment with low doses of amisulpride, a selective antagonist at the dopamine D2 and D3 receptors. Smoking and excessive caffeine use are associated with poor therapeutic responses to clozapine and should be considered in the pharmacological management of treatment-refractory psychosis, regardless of the primary diagnosis.
超过30%对抗精神病药物治疗难治的精神障碍患者对氯氮平也无反应。尽管在精神科人群中吸烟和使用咖啡因的情况很普遍，但这些习惯通常被忽视，未被视为导致抗精神病药物治疗失败的因素。我们描述了2例患有严重难治性精神病的男性患者，1例患有精神分裂症，另1例患有双相情感障碍——两人均大量吸烟，后者还大量摄入咖啡因——他们的症状对氯氮平难治。当在住院环境中在监督下重新开始氯氮平治疗并考虑氯氮平、吸烟和咖啡因之间的药物相互作用时，两名患者的精神病症状均得到了显著、持续的改善。治疗策略包括逐渐增加氯氮平的每日剂量、监测氯氮平血浆水平、在夜间使用氯氮平的单次每日剂量，以及用低剂量的氨磺必利（一种多巴胺D2和D3受体的选择性拮抗剂）增强氯氮平治疗。吸烟和过量使用咖啡因与对氯氮平的治疗反应不佳有关，在难治性精神病的药物管理中应予以考虑，无论其主要诊断如何。
