Azithromycin in the Management of Clozapine-Induced Gastrointestinal Hypomotility

Research and clinical attention on clozapine-induced gastrointestinal hypomotility (CIGH) tends to focus primarily on constipation. However, CIGH is known to affect all aspects of the GI tract including gastric emptying and esophageal hypomotility. We report on the presentation, diagnosis, and treatment of two pediatric patients who presented with CIGH affecting sites other than the colon, the first with gastric and the second with esophageal manifestations. First, a 14 year old female with globus sensation, coughing, and concern for aspiration that did not respond to other treatments. Second, a 16 year old female with substantial gastroparesis and vomiting following increase in clozapine dose. This patient was not a candidate for more typical pharmacologic interventions due to QTc prolongation. Both patients were treated successfully with azithromycin, which has been previously explored in the treatment of gastroparesis, but not specifically in CIGH. Notably, both also experienced improvements in ability to clear secretions (particularly significant given the potential for sialorrhea in clozapine) implying a potential benefit to the pharygneal swallowing phase which is also known to be impacted by antipsychotics. We will discuss the prevalance of esophageal and gastric symptoms in CIGH, treatments for esophageal and gastric hypomotility, with the former being known to be difficult to manage, and the unique qualities of azithromycin when compared to other agents. This case study unveils an important discussion on the future treatment of CIGH and provides preliminary evidence for the use of azithromycin over other medications when gastroparesis and esophageal hypomotility symptoms are present.