Curr Psychiatry Rep (2011) 13:156165
DOI 10.1007/s11920-011-0185-3
Genetics of Antipsychotic-induced Side Effects
and Agranulocytosis
Nabilah I. Chowdhury & Gary Remington &
James L. Kennedy
Published online: 19 February 2011
# Springer Science+Business Media, LLC 2011
Abstract Antipsychotic medication has been enormously
helpful in the treatment of psychotic symptoms during the past
several decades. Unfortunately, several important side effects
that can cause significant morbidity and mortality. The two
most common are abnormal involuntary movements (tardive
dyskinesia) and weight gain progressing through diabetes to
metabolic syndrome. A more rare and life-threatening adverse
effect is clozapine-induced agranulocytosis (CIA), which has
been linked to clozapine use. Clozapine itself has a unique
position among antipsychotic medications, representing the
treatment of choice in refractory schizophrenia. Unfortunately,
the potential risk of agranulocytosis, albeit small, prevents the
widespread use of clozapine. Very few genetic determinants
have been clearly associated with CIA due to small sample
sizes and lack of replication in subsequent studies. The HLA
system has been the main hypothesized region of interest in
the study of CIA, and several gene variants in this region have
been implicated, particularly variants of the HLA-DQB1 locus.
A preliminary genome-wide association study has been
conducted on a small sample for CIA, and a signal from the
HLA region was noted. However, efforts to identify key gene
mechanisms that will be useful in predicting antipsychotic side
effects in the clinical setting have not been fully successful,
and further studies with larger sample sizes are required.
N. I. Chowdhury : J. L. Kennedy (*)
Neurogenetics Section, Neuroscience Department,
Centre for Addiction and Mental Health,
250 College Street,
Toronto, Ontario M5T 1R8, Canada
e-mail: james_kennedy@camh.net
G. Remington
Schizophrenia Program, Centre for Addiction and Mental Health,
250 College St.,
Toronto, Ontario M5T 1R8, Canada
e-mail: gary_remington@camh.net
Keywords Antipsychotics . Agranulocytosis .
Clozapine-induced agranulocytosis . Tardive dyskinesia .
Weight gain . Genetics . Association study .
Pharmacogenetics
Introduction
Schizophrenia, a chronic, debilitating mental disorder that
affects about 1% of the general population, is most
commonly treated with second-generation antipsychotic
medication [1]. First- and second-generation antipsychotic
medications can have severe side effects. These include, but
are not limited to, tardive dyskinesia (TD), antipsychotic-
induced weight gain, and agranulocytosis, all of which
significantly affect patient quality of life.
The side effects of antipsychotic drugs are experienced
by many patients who are given these treatments. The first-
generation antipsychotics tend to result in the development
of TD, a potentially permanent abnormality of motor
movements, in 20% to 30% of patients. Second-
generation antipsychotics, particularly clozapine and olan-
zapine, tend to lead to increased weight gain, hyperlipid-
emia, hyperinsulinemia, and other changes that lead to
metabolic syndrome. Although clozapine is the gold
standard treatment for core schizophrenia symptoms, it
remains highly underused by physicians. The occurrence of
metabolic syndrome as a result of clozapine is one factor
that contributes to physicians reluctance to prescribe it.
Importantly, the rare but deadly side effect known as
agranulocytosis, a rapid decline in white blood cell count,
also has been reported to occur as a result of clozapine
treatment. Therefore, the combination of increased risk of
development of metabolic syndrome or agranulocytosis
inhibits prescription of effective drugs such as clozapine.
Curr Psychiatry Rep (2011) 13:156165
The mechanisms underlying the development of these side
effects have yet to be elucidated. Genetic factors are likely
to contribute to the development of antipsychotic-induced
side effects.
A considerable interindividual variation of side effect
development to these drugs exists, suggesting a genetic
component. For instance, antipsychotic-induced weight
gain has been estimated to have a heritability of 0.6 in
schizophrenia patients [2]. If patients at higher risk of
development of antipsychotic induced side effects could be
identified before treatment, this could aid clinicians in
choosing the optimum treatment for their patients. Apply-
ing the principle of pharmacogenetics to a clinical setting
would result in physicians having the ability to decide
which types of medications would work for a given patient.
However, the actual application of personalized medicine in
patients has yet to be widely implemented for psychiatric
disorders. This is due in part to factors such as many studies
having small sample sizes, conflicting or unreplicated
findings, and the fact that psychiatric phenotypes tend to
be complex [1]. However, as we review below, the
understanding of genetic contribution to these side effects
has had some promising success in the past decade.
Pharmacogenetics of Tardive Dyskinesia
Tardive dyskinesia (TD) is a side effect that is typically
experienced by schizophrenia patients given first-
generation antipsychotic treatment, and potentially results
in permanent abnormal motor movements. Thus far,
dopamine system genes encoding for dopamine D2 and
D3 receptors, as well as the catechol-o-methyltransferase
(COMT) enzyme, have been implicated in the development
of TD. The D2 receptor is a primary target for all
antipsychotics and has therefore been the focus of several
studies investigating antipsychotic-induced side effects. The
Taq1A polymorphism (rs1800497) is located downstream
of DRD2 and is a nonsynonymous coding single nucleotide
polymorphism (SNP) in the ankyrin repeat gene (ANKK1
Glu713Lys). This marker has been extensively studied in
the pharmacogenetics of TD. The minor T allele of the Taq
1A site appears to be protective against TD [3, 4] and has
been associated with a 40% reduction in striatal D2 receptor
density [5, 6].
The D3 receptor also has been implicated in antipsy-
chotic mechanism of action [7]. The rs6280 SNP is a
functional missense variant that results in a Ser to Gly
substitution at amino acid nine [8]. Some studies have
reported that the Gly variant carriers exhibit enhanced
symptom response to certain antipsychotics (eg, clozapine
or risperidone). In addition, Gly carriers have been reported
to be at significant risk of developing TD [914]. A recent
157
study investigated the large Clinical Antipsychotic Trials of
Intervention Effectiveness (CATIE) clinical trial sample
with TD and reported no effects of either DRD3 Ser9Gly or
the DRD2 region Taq1A site [15]. The mixed results for the
DRD3 Ser9gly may be due to the fact that other markers in
the DRD3 are also involved [16]. A haplotype containing
rs3732782, rs905568, and rs7620754 in the 5 region of
DRD3 was associated with TD (permuted P=0.007).
The COMT enzyme is the primary mechanism of
dopamine clearance in the frontal cortex. Gene variants of
COMT have been implicated with TD. The functional
COMT polymorphism, which codes for a substitution of
methionine (met) for valine (val) at codon158, has been
reported to have an association with TD. The val allele
results in reduced synaptic dopamine due to more rapid
clearance [17]. A recent meta-analysis reported that the val
allele is associated with a modest increased risk of TD (OR,
1.19) [18].
Aside from dopaminergic genes, other pathways and
candidate genes also have been proposed to be involved in
the development of TD. Recent studies have suggested that
an accumulation of free radicals or oxidative stress may be
associated with development of TD [19]. Superoxide
dismutase (SOD) is a mitochondrial enzyme involved in
oxidative metabolism and therefore has a role in protecting
cells from free radical damage [19]. SOD has been reported
to be altered in TD patients, and decreased SOD levels are
significantly correlated with dyskinetic movements in TD
patients. The manganese isoform of this enzyme (MnSOD),
has been particularly implicated with TD [19, 20]. The
functional Ala9Val (rs4880) polymorphism in exon 2 of the
MnSOD gene has been reported to be involved in TD, as
the Ala-to-Val substitution may result in the alteration of
MnSOD activity in human mitochondria. Homozygote
carriers for the ala variant are approximately twice as likely
to develop TD compared with the val carriers [21]. Recent
meta-analyses have yielded mixed results for the associa-
tion between TD and MnSOD. Bakker et al. [18] reported a
protective effect against TD for the val carriers using ala/ala
homozygotes as a reference category. However, Zai et al.
[22] found no significant association of MnSOD genotypes
or alleles in TD occurrence in a recent meta-analysis.
Other genes that have been implicated in TD include
serotonergic genes. The 5-HT2A receptor gene (HTR2A)
has been thoroughly investigated in pharmacogenetic
studies of TD. The C-allele of the promoter region SNP
(T102C or rs6313) has been associated with increased risk
of TD in older patients (>47 years of age) [23]. However,
some studies have reported no association with this
polymorphism and TD [24]. The highly polymorphic
CYP2D6 liver enzyme gene also has been implicated in
TD. Typically, reduced CYP2D6 activity can be expected to
result in a higher effect dose as measured by blood levels of
158
the active drug. A meta-analysis showed a moderate effect
of loss-of-function alleles on risk of TD, with homozygotes
having greater odds of experiencing TD [25].
Pharmacogenetics of Antipsychotic-induced Weight
Gain
Although TD is typically induced by first-generation
antipsychotics, the propensity for weight gain resulting
from second-generation antipsychotic drug treatment occurs
in about 30% of schizophrenia patients [26, 27]. Other
metabolic abnormalities also observed in this group of
patients include hyperglycemia, hyperlipidemia, and hyper-
phagia. These undesired effects often lead to noncompli-
ance to medication. If the patients are compliant and
continue to take the medication long term, they are at
increased risk of developing potentially fatal illnesses,
including diabetes and cardiovascular disease.
Although several studies have investigated candidate
genes in antipsychotic-induced weight gain, genes in the
serotonergic and leptinergic systems have been the most
consistently implicated with this side effect. Thus far, the
most consistent association with weight has been with the
5-HT2C receptor gene. The -759C/T polymorphism in the
promoter region of HTR2C was first studied by Reynolds et
al. [28], who reported that this variant was associated with
altered body mass index after 6 to 10 weeks of antipsy-
chotic treatment in drug-nave patients. In addition, the -
759T variant also has been associated with reduced weight
gain in first-episode psychosis patients, multiepisode
patients, and treatment-resistant patients. Thus, several
studies confirmed a protective effect of the -759T variant
for antipsychotic-induced weight gain. This -759 variant is
located near a transcription factor binding site and therefore
may be functional in terms of regulating gene expression.
However, findings are mixed for this polymorphism. A
meta-analysis conducted by De Luca et al. [29] reported a
slight association between -759C/T and antipsychotic-
induced weight gain. Most recently, Sicard et al. [30]
performed a meta-analysis also supporting this finding.
The leptin and leptin receptor gene have also been
implicated in antipsychotic-induced weight gain. The
hormone leptin has a significant role in the physiology of
food intake and energy homeostasis. Specifically, the
functional leptin promoter 2458G/A marker has been
reported to be associated with antipsychotic-induced weight
gain. In general obesity studies, the -2458G allele has been
associated with participants being overweight [31]. One
recent study also found that the -2458 marker is associated
with long-term (9 months) antipsychotic-induced weight
gain [32]. A recent study found the -2458G allele to be
associated with clozapine-induced weight gain in a Chinese
Curr Psychiatry Rep (2011) 13:156165
Han population [33]. The investigators found that this
polymorphism accounted for 9% of the variance in weight
gain. Overall, it is likely that several gene systems are
involved with this side effect. More recently, other genes,
such as the -2A adrenergic receptor, have also been
reported to be associated with weight gain. Carriers of the
C-allele (CC+ CG vs GG) were more likely to gain weight
[34]. However, the 1291-C/G polymorphism was reported
not to be a strong predictor of long-term occurrence of the
metabolic syndrome in patients using antipsychotics [35].
The modest effect sizes in the positive studies suggest that
multiple genetic and environmental factors contribute to
antipsychotic-induced weight gain. Thus, before genetic
tests for risk of antipsychotic-induced weight gain are
brought into the clinical domain, there is a need for further
exploration of the underlying mechanisms regarding gene
variants in antipsychotic-induced weight gain.
Psychiatric Drugs and Hematologic Side Effects
The main adverse effect of antipsychotic medications on the
blood system is the destruction of defensive white blood
cells. The neutrophils are the subtype of white cells most
often at risk of deleterious effects of antipsychotics and
many other medications. Neutropenia, defined as a neutro-
phil count of less than 1,500 cells/mm3, is a rare potential
side effect that occurs in conjunction with many classes of
drugs. Agranulocytosis represents a subtype of neutropenia
characterized by a substantial and potentially fatal decrease
in the number of neutrophil granulocytes in circulating
blood (<500 cells/mm3) [36]. These values are somewhat
arbitrary, however, and differences in threshold criteria can
be found; however, most studies have used the cutoff of
500 cells/mm3. Antipsychotic use dates back to the early-
1950s, beginning with chlorpromazine, and neutropenia
was quickly identified as a potential side effect [37]. The
second-generation antipsychotic clozapine has received the
most attention for its potential to cause loss of neutrophils
and agranulocytosis. Neutropenia has been reported in
association with other second-generation antipsychotics
[37] as well as the antiepileptics/mood stabilizers. For
example, the risk of developing neutropenia in patients
taking carbamazepine is estimated to be about 1 in 200
[37]. It has been suggested that agranulocytosis is caused by
reactive metabolites generated by the myeloperoxidase
(MPO) system of white blood cells. A study assessing
metabolism and covalent binding of carbamazepine with
MPO components in neutrophils found that the MPO system
is involved in the metabolism of carbamazepine by neutro-
phils [38]. The findings suggest that carbamazepine is
metabolized by reactive intermediates in activated leuko-
cytes. The authors suggested that drug metabolites could be
Curr Psychiatry Rep (2011) 13:156165
responsible for the agranulocytosis development observed in
some patients who were taking carbamazepine [38].
Clozapine and Agranulocytosis
Clozapine is the prototype of atypical antipsychotics,
with its clinical use dating back to the 1960s. Clinically, it
distinguished itself from other antipsychotics (now referred
to as conventional or typical) by its lack of extrapyramidal
symptoms at therapeutic doses [39, 40], which came to
define atypicality [41]. However, its use was significantly
curtailed following a cluster of deaths shortly after it gained
widespread clinical use in the early-1970s. Only after the fact
were the deaths linked to agranulocytosis [39, 40]. More
restricted use continued thereafter, and by the late-1980s, a
seminal study carried out in the United States established the
clinical superiority of clozapine in treatment of refractory
schizophrenia [42]. By the 1990s, clozapine was being
reintroduced more globally once again, but with the requisite
of routine hematologic monitoring. Figures suggested that
clozapine-induced agranulocytosis (CIA) occurs in roughly
0.8% of those treated (range, 0.42%) [43, 44]. Careful
attention toward blood cell monitoring has reduced the
number of deaths associated with clozapine use, and risk of
death from CIA is estimated to be about 1 in 10,000 [45].
Currently, clozapine use is reserved for schizophrenia
patients who are refractory to previous antipsychotic trials,
but even in this subpopulation, it seems underutilized [46,
47]. The risk of CIA, in combination with the need for
routine and continuous hematologic monitoring, deters
many individuals who are potential candidates for cloza-
pine, as it is estimated that as many as 25% of individuals
with schizophrenia are refractory to standard antipsychotic
treatment [48]. Establishing who is at risk of developing CIA
would represent a significant step forward, but as of yet, the
mechanism(s) underlying CIA remain poorly understood. The
fact that only a small subset of the population is at risk, as well
as the success of genetic investigations of several other rare
medication side effects (eg, Stevens-Johnson syndrome [49])
argues strongly for a genetic component to CIA. If a clear
genetic link to CIA is discovered, a predictive test could be
developed; however, the relative rarity of CIA significantly
limits collection of the large samples required to conduct
robust genomic studies.
Clozapine-induced Agranulocytosis and Theoretical
Mechanisms
Studies to date provide a limited understanding of the
genetic components that are involved in the development of
CIA. One theory is that the activation of electrophilic
159
nitrenium ions by clozapine and its metabolites is the first
step in the development of agranulocytosis [50, 51]. It has
been shown, for example, that neutrophils generate hypochlo-
rous acid via NADPH oxidase/myeloperoxidase, which oxi-
dizes clozapine [5255]. It has been proposed that that these
ions may bind to neutrophils to cause cell death; alternatively,
they could cause oxidative stress-induced neutrophil apoptosis
[56]. Past studies have also reported associations with HLA
gene variants, suggesting an immune-mediated mechanism.
Clozapine metabolite-induced neutrophil toxicity and immune
system mediation are maintained as the most prevalent
theories of mechanisms underlying CIA.
Overview of Genetics of Clozapine-induced
Agranulocytosis (Major Histocompatibility
Complex Region)
In 1977, de la Chapelle and colleagues [57] and Amsler et
al. [58] first reported blood dyscrasias as a result of clozapine;
once documented, several CIA cases (N=16) were identified.
Although no genetic mechanism was uncovered, this was
suggested as a likely possibility [57]. Studies in the early-
1990s reported that HLA haplotypes were associated with
CIA in patients of European ancestry with schizophrenia,
particularly those of Jewish ancestry. The HLA alleles or
haplotypes are variants of the major histocompatibility
complex (MHC) region, a complex genomic area composed
of many genetic variants located on the short arm of
chromosome 6 (6p21.31-32). The HLA class I and class II
antigens have been the most extensively studied in CIA, and
given that these alleles are implicated in immune system
function, it was reasonable to investigate associations
between polymorphisms in these genes and CIA (Table 1).
The first case-control study, by Lieberman et al. [59]
found that the HLA-B38 marker was present in 83% of 6
patients versus 20% of 25 controls. Furthermore, the
haplotype composed of the HLA-B38, -DR4, and -DQ3
alleles was also shown to be associated with CIA in 100%
of cases, as opposed to 12% of controls. These haplotypes
were more prevalent in patients with CIA compared with
patients without CIA, and both groups were of Ashkenazi
Jewish ancestry. In an updated report from the same group,
Yunis et al. [60] reported an association of CIA with the
HLA-DRB1-0402, -DQB1-0302, and -DQA1-0301 markers
in patients of Ashkenazi Jewish ancestry [60]. In addition,
they noted that HLA-DR-02, -DQB1-0502, and DQA1-0102
were associated with CIA in patients of non-Jewish
European ancestry. Valevski et al. [61] identified an
association of HLA-B38 antigen with CIA in 61 Jewish
Israeli schizophrenia patients with CIA, and suggested that
gene variants in the HLA region were involved in CIA
development. Another study reported that the HLA-
160
Table 1 Candidate genes implicated in the development of CIA
DQB1*0201 variant was present in five of five patients
who developed neutropenia, in contrast to approximately
half of patients who did not develop this side effect [62].
However, methodologic and statistical shortcomings in
these studies, including very small sample size and lack
of detailed clinical information, may account at least in part
for failure to replicate these findings. Dettling and
colleagues [63] assessed a sample with patients of German
ancestry and reported an association between CIA and the
HLA-DQB-0201 and HLA-Cw-7 alleles. For HLA class II
alleles, HLA-DQB-0502, -DRB1-0101, and -DRB3-0202 were
Curr Psychiatry Rep (2011) 13:156165
found to be associated with CIA, but in contrast to previous
findings, no significant association was found between CIA
and the HLA-B38 allele [63]. More recently, Dettling et al.
[64] identified a significant association with CIA for two Cw-
7-related two-locus haplotypes with HLA-Cw7-B18 and HLA-
Cw7-B39; one HLA class II two-locus haplotype with HLA-
DRB5-0201-DRB4; and a three-locus haplotype with HLA-
Cw7drb5, HLA-Cw7-B39-DRB5, and HLA-Cw7-B44-DRB5.
The authors concluded that combinations and possibly
epistasis of alleles or haplotypes at several HLA class I loci,
spanning from MHC-I over MHC-III to MHC-II, may be
Curr Psychiatry Rep (2011) 13:156165
relevant. These separate loci within the MHC all have their
different and specific roles in immunologic responses that may
contribute independently to the risk of CIA [65].
At this point, the potential role of the genetics of HLA alleles
in CIA remains unclear. One proposed mechanism is that the
HLA alleles may induce cytotoxic effects in clozapine-treated
patients [66]. However, the genetic mechanisms underlying
CIA are likely multifaceted, and the role of these alleles may
be interactive with other genetic sites. The granulocyte
colony-stimulating factor (G-CSF) receptor gene is of interest
given that G-CSF is used in the treatment of neutropenia. A
patient with severe congenital neutropenia was treated with
recombinant GCS-F, which resulted in an increased neutrophil
count [67]. It is possible that a failure of endogenous G-CSF is
involved in risk of neutropenia. G-CSF (filgrastim) has been
used to treat CIA [6870].
During the years 2002 through 2007, PGxHealth (New
Haven, CT), a subsidiary of Clinical Data (Newton, MA),
collected a series of CIA cases from the eastern United States
and then accessed a German cohort [30] as a replication
sample. An initial genome-wide association study (GWAS)
was conducted on 33 cases and 54 controls; the German
replication sample consisted of 49 cases of patients with CIA.
Loci highlighted as significant in the GWAS included HLA-
DQB1, granulocyte-colony stimulating factor receptor (G-
CSFR), and dopamine receptor D1. The investigators also
found that a variant in HLA-DQB1, 6672G>C, was associated
with risk of CIA, reporting a 16.9 times increased risk for
carriers of this marker [64]. A commercial test was marketed
in 2007 based on data from 136 patients in the cohorts
utilizing the HLA-DQB1 6672G>C genotype to classify
patients as lower risk or higher risk for CIA. Test
sensitivity and specificity were calculated to be 21.5% and
98.4%, respectively, indicating that about one in five patients
at risk of CIA would be identified by the test. The scientific
data behind the test were recently published [71]. Although
the HLA-DQB1 locus may be implicated in CIA development,
low sensitivity of the test has been a limiting factor in its
application in clinical settings.
Although HLA sites in the MHC region may be promising
candidates for genetic mediation of CIA, other non-HLA
genes in the MHC region also have been investigated. For
example, heat shock protein (HSP) loci [33] and the tumor
necrosis factor (TNF)- gene both have been implicated [34].
Corzo et al. [72] reported that HSP70, 9-kb variant is
associated with HLA haplotypes prevalent in patients with
CIA of both Jewish and non-Jewish ancestry. Interestingly,
HSP70-1C and HSP-2, 8.5-kb variants were higher in
frequency in the control group, suggesting that these variants
may be protective against CIA risk. In the case of TNF-,
patients of both Jewish and non-Jewish ancestry had higher
levels of microsatellites compared with controls, while the b5
microsatellite was lower in frequency in these patients
161
compared with controls [73]. The authors suggest that
investigating neutrophils and their rate of survival in the
presence of clozapine and its metabolites could prove useful in
establishing the role of TNF- in CIA, as it has been reported
that some HLA haplotypes are associated with higher
production of TNF- and TNF- [74]. Furthermore, obser-
vations that TNF microsatellites and the HLA-DR genotype
influence TNF- secretions provides evidence that TNF-
may be involved in CIA. The role of these variants in the
pathology of CIA remains unclear and without replication;
however, one recent study examined how an oxidized
clozapine metabolite affects human polymorphonuclear cells
in vitro [75]. FCRIIIb (CD16) receptors specifically were
evaluated, as these have been implicated in cellular apoptosis
and cytotoxicity [76], and apoptotic neutrophils are susceptible
to Fas-induced death [77]. Fas is a 45-kDa type I membrane
protein expressed on granulocyte surfaces, while FasL is a 40-
kDa type II protein of the TNF family [37]. A Fas/FasL
interaction is thought to trigger apoptosis of granulocytes.
Husain et al. [75] reported that decreased CD16 and increased
FasL expression were associated with changes in granulocytes
cultured with oxidized clozapine, suggesting a role for Fas/
FasL interaction in CIA. Future directions include measuring
TNF expression in patients to determine if its dysregulation
plays a critical role in agranulocytosis.
Other Non-Major Histocompatibility Complex
Candidate Genes for Clozapine-induced Agranulocytosis
One recently studied candidate gene, dihydronicotinamide
riboside quinine oxidoreductase 2 (NQO2), has also been
implicated in the genetic mediation of CIA [78]. The NQO2
gene is located on chromosome 6p25 and has many highly
polymorphic variants. NQO2 has been implicated in the
detoxification of chemicals and protection of cells against
drug-induced oxidative and electrophilic stress. The level of
NQO2 mRNA has been reported as lower by quantitative
reverse transcriptase polymerase chain reaction in patients
with agranulocytosis as compared with a control group.
Ostrousky and colleagues [78] suggested that clozapine
metabolites accumulate in neutrophil granulocytes due to
insufficient detoxification of clozapine, resulting in neutro-
phil apoptosis.
Interestingly, there is no reported association between
the cytochrome P450 enzyme gene variants and the
development of agranulocytosis, arguing against a dose-
dependent effect or a toxic metabolite [79]. Other candidate
genes, including MPO and NADPH oxidase, also have been
implicated in CIA [80]. Clozapine stimulates the release of
cytokines and soluble cytokine receptors, leading to the
release of MPO and induction of NADPH oxidase; these in
turn work in conjunction to form the major oxidation
162
function in neutrophils [80]. It has been hypothesized that
because NADPH oxidase and MPO may oxidize clozapine
to highly reactive nitrenium ions, polymorphisms of these
genes may be involved in CIA. The NADPH subunit CYBB
was sequenced, found to be a highly conserved gene with
little variation across humans, and therefore judged to not
be involved as a risk factor in CIA. For the MPO gene, in
terms of allele frequencies, it was found that the low-
activity MPO -436A variant frequency was 22.2% in cases
and 19.9% in controls. Of more interest, in terms of
genotypes, AA carriers were overrepresented among cases
compared with the sum of AG and GG carriers (OR, 4.16;
95% CI, 0.8620.3; P=0.056). Among the drugs studied,
the effect was slightly more significant (P=0.04) in CIA.
Overall, the purported MPO gene association with CIA is
very weak, and its role remains unclear.
Based on the fact that some immunoglobulins are widely
expressed in neutrophils, it has been proposed that poly-
morphisms in the genes for these immunoglobulins may be
involved in CIA. Clinically relevant polymorphisms of IgG
or Fc receptors have been assessed in clozapine-treated
patients, although no associations between these poly-
morphisms and CIA have been established [36].
Conclusions and Future Directions
Clinical application of genetic testing for antipsychotic-
induced side effects is not yet ready for widespread use;
however, as reviewed above, there are some promising
developments that, with continued research, may be of
significant clinical benefit in the near future. For TD,
several candidate genes have been investigated to help us
further understand the development of this side effect in
first-generation antipsychotic treatment. Although the topic
has been extensively studied, mixed findings continue to
add to the complexity of TD development. There may be
promise in the use of combinations of markers at DRD2 and
DRD3 for clinically useful prediction of TD. In terms of
antipsychotic-induced weight gain and metabolic syndrome,
there are similar challenges. The serotonin 2C receptor has
been the most consistently replicated gene associated with
antipsychotic-induced weight gain. Further studies are re-
quired to investigate the role of other weight regulation
systems in the onset of antipsychotic-induced weight gain.
In the case of antipsychotic-induced agranulocytosis, one
would hope that the genetic etiology may be more simple
than for TD or weight gain because agranulocytosis is
relatively rare and arguably more resembling a simple
mendelian genetic disorder. The hypothesis that monoge-
netic mechanisms are involved in determining predisposi-
tion to CIA has been met with mixed results. The most
robust findings thus far involve gene variants of the HLA
Curr Psychiatry Rep (2011) 13:156165
region. The 6672G>C SNP of the HLA-DQB1 gene was
recently implicated and, in fact, incorporated into a
commercially available test [71]; however, its low sensitiv-
ity was a major issue that curtailed clinical utility.
Perhaps the field has been too focused on MHC gene
variants, however, several other biological systems have
been investigated. The NQO2 gene has been reported to be
influential in the development of CIA, with a reduction of
NQO2 mRNA levels in CIA patients compared with
controls, suggesting the genetic variant reduces transcrip-
tion or creates more unstable mRNA. Given that the Fas/
FasL interaction, in conjunction with clozapine metabolites,
may result in granulocyte apoptosis [78], the complexity of
possible genetic mechanisms in CIA may be very challenging.
We have described above that ethnic background may be
an important variable that influences the role of a given
gene variant in association with CIA. Many of the initial
investigations in CIA examined patients of Jewish ethnicity
[59, 60, 62, 73], although more recent studies have begun
to explore CIA in patient cohorts of varying ethnicities
[71]. Environmental factors also must be considered but as
yet have not been systematically evaluated. For example,
there is evidence that fluctuations in circadian rhythm
impact the number of circulating neutrophils in patients [37,
81]. Along similar lines, it has been demonstrated that
moderate exercise increases white blood cell count [37],
and typical schizophrenia patients usually have lower
interest in exercise. Thus, they may be less protected from
agranulocytosis than the general population.
At present, clozapine stands alone as the treatment of
choice in refractory schizophrenia, even among other
atypical antipsychotics [82, 83]. Furthermore, there is no
indication that its status in this regard will be challenged in
the foreseeable future. That as many as 25% of patients
with schizophrenia remain refractory to standard pharma-
cotherapy highlights the critical role of clozapine in
successful treatment of psychosis [48]. For clinicians and
patients, it would be invaluable to have a sensitive and
specific test for CIA that could guide decision making. This
is a compelling argument to continue the search for possible
genetic markers that alone or in combination may provide
such information. Genetic tools, including whole exome
and genome sequencing, as well as copy number variant
analyses, may elucidate rare variations that may be useful in
providing predictive measures to detect those patients who
are more likely to develop this potentially fatal side effect
[84]. The reported use of gene sequencing for the patient
cohorts to discover the role of HLA-DQB1 highlights a
key step forward in uncovering a genetic role in agranu-
locytosis [71]. In addition to the practical clinical value,
this type of information would prove extremely useful in
better understanding the underlying pathophysiology of
CIA.
Curr Psychiatry Rep (2011) 13:156165
Overall, as we further our knowledge of the mechanisms
of antipsychotic-induced side effects using powerful genetic
technologies, the development of more effective treatment
strategies and novel drug discovery will be enhanced.
Disclosure Dr. Gary Remington states that he has no conflict of
interest. Dr. James Kennedy has received funding from Eli Lilly.
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