Decoding the immunopharmacological basis of ECT-induced clozapine level elevation: Insights from a quantitative...

Electroconvulsive therapy (ECT), an effective augmentation for treatment-resistant schizophrenia, is associated with clinically significant, unpredictable elevations in serum clozapine concentrations, posing a substantial toxicity risk. Delirium, urinary retention, constipation, hypersalivation etc. have been frequently noticed. This study aimed to develop a quantitative systems pharmacology (QSP) model that provides a quantitative explanation for the observed clinical interaction. An integrated QSP model was constructed, incorporating a two-compartment pharmacokinetic model for clozapine, dynamic models for key inflammatory biomarkers (interleukin-6, C-reactive protein, tumour necrosis factor-alpha), and a mechanistic link representing their inhibitory effect on CYP1A2 enzyme activity. The model was parameterized using literature-derived data and retrospective clinical concordance was done against clinical findings at our centre. The model accurately simulates a progressive, multi-fold increase in clozapine concentrations over a course of six ECT sessions. This accumulation is mechanistically driven by a transient, pulsatile inflammatory response initiated by each ECT treatment. This response causes a cumulative, stepwise reduction in CYP1A2 activity, which reaches a nadir of approximately 30% of its baseline function. Consequently, simulated dopamine D₂ receptor occupancy surpasses the 80% threshold associated with an elevated risk of extrapyramidal symptoms following the fourth ECT session. The QSP model provides a robust, mechanistically plausible explanation for the observed ECT-clozapine interaction, identifying the inflammatory cascade as the critical driver of impaired clozapine metabolism. The model serves as a powerful tool for simulating patient risk and provides a quantitative foundation for developing personalized, model-informed dosing strategies to enhance the safety of this crucial concomitant therapy.