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Case report
Paradoxical refractory hypotension following adrenaline administration in a patient taking clozapine
  1. Anand Alagappan1,
  2. Rosaleen Baruah1,
  3. Alastair Cockburn2 and
  4. Euan A Sandilands3,4,5
  1. 1Department of Intensive Care and Anaesthesia, Western General Hospital, NHS Lothian, Edinburgh, UK
  2. 2Department of Adult Psychiatry, Royal Edinburgh Hospital, NHS Lothian, Edinburgh, UK
  3. 3Department of Acute Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
  4. 4Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
  5. 5National Poisons Information Service (Edinburgh unit), Edinburgh, UK
  1. Correspondence to Dr Euan A Sandilands; euan.sandilands{at}nhslothian.scot.nhs.uk

Abstract

Clozapine is a potent antipsychotic commonly used for refractory schizophrenia. Adverse effects are well recognised including constipation, intestinal obstruction, agranulocytosis and cardiomyopathy. We present a case of paradoxical refractory hypotension following epinephrine administration in a patient taking clozapine. A psychiatric inpatient who had been taking clozapine for many years developed paralytic ileus and obstruction requiring surgical intervention. Following initiation of epinephrine administration intraoperatively he developed refractory hypotension which improved only when epinephrine was weaned off. This effect is likely due to uninterrupted β2-agonist activity in the presence of clozapine-induced α-blockade. Clinicians need to have greater awareness of this serious interaction and avoid the use of epinephrine in patients taking clozapine.

  • anaesthesia
  • adult intensive care
  • pharmacology and therapeutics
  • schizophrenia

https://doi.org/10.1136/bcr-2021-243363

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    Footnotes

    • Contributors AA: responsible for patient care, planning of case report, literature review, writing and editing manuscript. RB: responsible for patient care, writing and editing manuscript. AC: responsible for patient care, writing and editing manuscript. EAS: responsible for planning of case report, literature review, writing and editing manuscript. All authors reviewed the final manuscript and guarantors for the content of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.