Wikipedia / Zuclopenthixol
Wikipedia / Zuclopenthixol
Zuclopenthixol (brand names Cisordinol, Clopixol and others), also known as zuclopentixol, is a medication used to treat schizophrenia and other psychoses. It is classed, pharmacologically, as a typical antipsychotic. Chemically it is a thioxanthene. It is the cis-isomer of clopenthixol (Sordinol, Ciatyl). Clopenthixol was introduced in 1961, while zuclopenthixol was introduced in 1978.
Zuclopenthixol is a D1 and D2 antagonist, α1-adrenergic and 5-HT2 antagonist. While it is approved for use in Australia, Canada, Ireland, India, New Zealand, Singapore, South Africa and the UK, it is not approved for use in the United States.
Medical uses
Available forms
Zuclopenthixol is available in three major preparationss:
As zuclopenthixol decanoate (Clopixol Depot, Cisordinol Depot), it is a long-acting intramuscular injection. Its main use is as a long-acting injection given every two or three weeks to people with schizophrenia who have a poor compliance with medication and suffer frequent relapses of illness. There is some evidence it may be more helpful in managing aggressive behaviour.
As zuclopenthixol acetate (Clopixol-Acuphase, Cisordinol-Acutard), it is a shorter-acting intramuscular injection used in the acute sedation of psychotic inpatients. The effect peaks at 48–72 hours providing 2–3 days of sedation.
As zuclopenthixol dihydrochloride (Clopixol, Cisordinol), it is a tablet used in the treatment of schizophrenia in those who are compliant with oral medication.
It is also used in the treatment of acute bipolar mania.
Dosing
As a long-acting injection, zuclopenthixol decanoate comes in a 200mg and 500mg ampoule. Doses can vary from 50mg weekly to the maximum licensed dose of 600mg weekly. In general, the lowest effective dose to prevent relapse is preferred. The interval may be shorter as a patient starts on the medication before extending to 3 weekly intervals subsequently. The dose should be reviewed and reduced if side effects occur, though in the short-term an anticholinergic medication benztropine may be helpful for tremor and stiffness, while diazepam may be helpful for akathisia. 100mg of zuclopenthixol decanoate is roughly equivalent to 20mg of flupentixol decanoate or 12.5mg of fluphenazine decanoate.
In oral form zuclopenthixol is available in 2, 10, 25 and 40mg tablets, with a dose range of 2060mg daily.
Side effects
Chronic administration of zuclopenthixol (30mg/kg/day for two years) in rats resulted in small, but significant, increases in the incidence of thyroid parafollicular carcinomas and, in females, of mammary adenocarcinomas and of pancreatic islet cell adenomas and carcinomas. An increase in the incidence of mammary adenocarcinomas is a common finding for D2 antagonists which increase prolactin secretion when administered to rats. An increase in the incidence of pancreatic islet cell tumours has been observed for some other D2 antagonists. The physiological differences between rats and humans with regard to prolactin make the clinical significance of these findings unclear.
Withdrawal syndrome: Abrupt cessation of therapy may cause acute withdrawal symptoms (eg, nausea, vomiting, or insomnia). Symptoms usually begin in 1 to 4 days of withdrawal and subside within 1 to 2 weeks.
Other permanent side effects are similar to many other typical antipsychotics, namely extrapyramidal symptoms as a result of dopamine blockade in subcortical areas of the brain. This may result in symptoms similar to those seen in Parkinson's disease and include a restlessness and inability to sit still known as akathisia, a slow tremor and stiffness of the limbs. Zuclopenthixol is thought to be more sedating than the related flupentixol, though possibly less likely to induce extrapyramidal symptoms than other typical depots. As with other dopamine antagonists, zuclopenthixol may sometimes elevate prolactin levels; this may occasionally result in amenorrhoea or galactorrhoea in severe cases. Neuroleptic malignant syndrome is a rare but potentially fatal side effect. Any unexpected deterioration in mental state with confusion and muscle stiffness should be seen by a physician.
Zuclopenthixol decanoate induces a transient dose-dependent sedation. However, if the patient is switched to maintenance treatment with zuclopenthixol decanoate from oral zuclopenthixol or from i.m. zuclopenthixol acetate the sedation will be no problem. Tolerance to the unspecific sedative effect develops rapidly.
Very common Adverse Effects (≥10% incidence)
Hypersalivation
Common (1–10%)
Abnormal vision
Salivary hypersecretion
Constipation
Vomiting
Fatigue
Pain (at the injection site)
Increased appetite
Weight gain
Tremor
Dizziness
Headache
Disturbance in attention
Abnormal gait
Abnormal dreams
Agitation
Decreased libido
Nasal congestion
Uncommon (0.1–1%)
Abdominal pain
Nausea
Flatulence
Thirst
Abnormal liver function tests
Decreased appetite
Weight loss
Muscle rigidity
Speech disorder
Convulsion
Apathy
Nightmares
Libido increased
Confused state
Ejaculation failure
Erectile dysfunction
Female orgasmic disorder
Vulvovaginal
Dryness
Rash
Pigmentation disorder
Dermatitis
Hot flush
Rare (0.01–0.1%)
Hypersensitivity
Glucose tolerance impaired
Withdrawal symptoms
Very rare (<0.01%)
Pharmacology
Pharmacodynamics
Zuclopenthixol antagonises both dopamine D1 and D2 receptors, α1-adrenoceptors and 5-HT2 receptors with a high affinity, but has no affinity for muscarinic acetylcholine receptors. It weakly antagonises the histamine (H1) receptor but has no α2-adrenoceptor blocking activity .
Evidence from in vitro work and clinical sources (i.e. therapeutic drug monitoring databases) suggests that both CYP2D6 and CYP3A4 play important roles in zuclopenthixol metabolism.
Pharmacokinetics
History
Zuclopenthixol was introduced by Lundbeck in 1978.
Society and culture
A 45‑year‑old Australian man died on 22 May 2019 in Balga from combined drug toxicity while under a community treatment order (CTO) that forced him to receive monthly depot injections of zuclopenthixol decanoate, which he frequently declined. The coroner concluded that, despite the death, the use of compulsory treatment was justified given the patient's "lack of insight" and the absence of alternative facilities.
References