Clozapine occupies high levels of dopamine D2 receptors

An important discrepancy has been noted concerning the number of dopamine D2 receptors which must be occupied in patients by clozapine, in contrast to other antipsychotic drugs, in order to achieve an antipsychotic effect. For example, when D2 receptors are labelled by radioactive raclopride or spiperone congeners in patients, psychosis-controlling doses of all antipsychotic drugs occupy about 70% or more of the D2 receptors in patients. However, equi-effective psychosis-controlling doses of clozapine (approximately 400 mg/day; approximately 70-130 nM in spinal fluid) only occupy between 20% and 50% of the D2 receptors in patients. This discrepancy of a consistently lower occupancy of D2 by psychosis-controlling doses of clozapine may be resolved when one considers that the neuroleptic concentration for half-occupancy of D2 receptors in vitro (i.e. the inhibition constant) depends on the radioligand used to label the receptor. Radioligands with higher tissue/buffer partition coefficients are less displaced by clozapine. This principle applies both in vitro and in vivo. Thus, allowing for this principle, psychosis-controlling doses of clozapine can be shown to occupy over 70% of the brain dopamine D2 receptors in patients, as found with other neuroleptics.