Abstract
To the Editor
Clozapine can cause gastro-oesophageal reflux disease (GORD) and haemetemesis (Adebayo et al., 2013; van Veggel et al., 2013). We share a case where combining Clozapine and Olanzapine induced severe reflux oesophagitis.
Case
Mr S, a 29-year-old man with schizophrenia, developed intermittent nausea and vomiting 1 month after commencing Clozapine. Esomeprazole 40 mg bd was started, but symptoms persisted over the next 6 years while Clozapine was uptitrated (750 mg daily) and Sodium Valproate (1500 mg daily) added, which contributed to frequent Clozapine refusal. A gastroscopy demonstrated grade C reflux oesophagitis.
During another relapse, Mr S was admitted and Olanzapine (30 mg daily) added to Clozapine and Sodium Valproate. Three days later, he developed heartburn requiring Gastrogel. On day 4, he developed vomiting and haematemesis (300 mL). Mr S was transferred to the emergency department where his vomiting resolved with Ondansetron 8 mg and observations stabilised. Investigations, including troponin and creatinine kinase (CK), were unremarkable, except a drop in Hb (138 to 122 g/L). Mr S returned to the psychiatric unit. Repeat gastroscopy demonstrated severe grade D reflux oesophagitis.
Given the possibility of the combined anticholinergic load contributing to this presentation, Olanzapine was changed to Haloperidol (10 mg nocte). Over the next week, his gastrointestinal symptoms improved with no further vomiting and once daily use of Gastrogel/Lignocaine for symptomatic relief.
Discussion
To our knowledge, this is the first case of Clozapine-related haematemesis in Australia. It also highlights the risk of severe upper gastrointestinal adverse effects when combining Clozapine and Olanzapine.
The temporal course in this case suggests a pathogenic role of combined Clozapine-Olanzapine therapy in causing Mr S’ symptoms. Both these antipsychotics have strong anticholinergic properties that increase the risk of GORD through muscarinic antagonism which relaxes the oesophageal sphincter (van Soest et al., 2008).
Besides contributing to non-adherence, combining anticholinergic antipsychotics with Clozapine can cause severe upper gastrointestinal symptoms and therefore warrants attention.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
