# One man's look at zuclopenthixol acetate

This article by Dan Polansky looks at zuclopenthixol acetate, a variant[terminology?] of zuclopenthixol and apparently a particularly potent and dangerous substance used in psychiatric drug interventions. This variant of zuclopenthixol has no dedicated Wikipedia article; only zuclopenthixol does, which refers to three variants per Wikipedia, with different potency.
This substance was administered to Jindřich Jašík, a Czech author of the book Journey out of Schizophrenia, 2019, in which he describes his experience with Czech psychiatric system as well as his approach toward self-treating his condition. The result of administration to Jašík was that he could not walk and talk; the administering personnel had to stop it before he reached the full dose (see a quotation at The case of Jindřich Jašík). One can expect this kind of outcome in a substance that is particularly potent/dangerous.
The above leads to research questions for this article:
* Is zuclopenthixol acetate very potent? To be done.
* Is zuclopenthixol acetate dangerous? Answered below in affirmative.
* What is the potency relationship between zuclopenthixol acetate and other zuclopenthixol formulations? To be done.
* Are there guidlelines online on administering zuclopenthixol acetate, especially such ones as suggest caution? Answered below; more can be done.
* What reports of adverse effects from zuclopenthixol acetate are available online? To be done.

## Brand names

Brand names of zuclopenthixol acetate are as follows:
* Clopixol Acuphase (no hyphen), apparently used in English-speaking countries including the U.K., Australia and South Africa (but not the U.S., apparently)
* Clopixol-Acuphase (with a hyphen): used in a leaflet for Canada
* Cisordinol-Acutard (with a hyphen): apparently used in non-English-speaking countries, with a hyphen, e.g. in Norway, Czechia, Denmark, Finland, Sweden, Latvia, etc.
* Cisordinol Acutard (no hyphen) is apparently used in Island and Austria.

## Producer

One producer is Lundbeck. To be found whether there are other producers. Wikipedia states that "Zuclopenthixol was introduced by Lundbeck in 1978", which is not specifically in reference to the acetate variant.
Lundbeck was criticized by Peter C. Gøtzsche.

## Required caution

An increased required caution follows from the following, a direct quotation from NHS Greater Glasgow and Glyde Guideline:
"Key Points
* Zuclopenthixol acetate (Clopixol Acuphase®) is NOT quick acting and should NOT be prescribed if immediate sedation is required. It is a potentially toxic and hazardous drug, which has the potential to be used inappropriately. There is little published data to support its use in psychiatric emergencies.
* The advice and authorisation of a consultant psychiatrist must be obtained before zuclopenthixol acetate is prescribed.
* Zuclopenthixol must never be given to anyone who has not previously received treatment with a first generation antipsychotic."

## Toxicity

Potential toxicity is asserted by NHS Greater Glasgow and Glyde Guideline and PsychDB.

## Misuse

According to psychdb.com: "Clopixol-Acuphase is widely misused, and in reality, can be a potentially toxic medication with poor evidence to support its use. However, it should be considered as a last line of effective short-term chemical restraint.". PsychDB "is made and run by a Canadian psychiatrist with an interest in medical education." The name of the Canadian psychiatrist is not provided, it seems. It is unclear that PsychDB is a reliable source.

## Dosage

As per U.K. leaflet, zuclopenthixol acetate is given to adults via intramuscular injections, at a usual dose of 50-150 mg, given repeatedly if necessary after 2-3 days; the total amount given in the treatment course shall be no more than 400 mg, in no more than 4 injections. This matches multiple other leaflets from the further reading. In case of doubt, better read the leaflet for full, non-rephrased information.
We can compare the above dosage to other zuclopenthixol variants:
* For zuclopenthixol "vanilla" tablets, "[t]he usual therapeutic range is 20 mg to 60 mg daily. Daily dosage higher than 100 mg is not recommended."
* For zuclopenthixol decanoate/Clopixol Depot, "[t]he usual maintenance dose is 150-300 mg intramuscularly, every 2-4 weeks. Some patients may require higher or lower doses, or shorter intervals between doses."
Let us do a comparison. If we reckon with 100 mg of zuclopenthixol acetate given every 2nd day up to the maximum dosage 400 mg, we get 50 mg per day during 8 days. If, by contrast, we reckon with 300 mg of zuclopenthixol decanoate every 2 weeks (14 days), we get 21 mg per day.

## The case of Jindřich Jašík

From the medical record of Jindřich Jašík, in relation to zuclopenthixol acetate/Cisordinol Acutard (the original is in Czech):
    "Medication included risperidol and clonazepam, but the patient did not take the pills and his condition worsened on the third day of hospitalization. Therefore, it was necessary to proceed to the injection of Cisordinol Acutard in combination with levomepromazine - the latter was then administered orally as well. The patient was calmer on this medication and more willing to cooperate, but showed signs of EPS syndrome. The dose of levomepromazine was thus reduced, no further injection of Cisordinol Acutard was administered. Instead, the patient was treated with olanzapine (20 mg pro die); temporary administration of Akineton. [...]"
The above is untrue: it was not necessary to use this drug, as should be obvious to anyone with a superficial acquaintance with the relevant psychiatric ontology and literature. The conditions required by NHS Greater Glasgow and Glyde Guideline for administration of zuclopenthixol acetate were not met above (see Required caution).
Jindřich Jašík's description of the effects of the medication, from a video, in Czech:
    "Pak jsem šel na injekci a po tý injekci si několik dní jako nepamatuju [...] já jsem pak nebyl schopnej chodit, mluvit, když jsem se měl najíst tak jsem se tak třebal že jsem nebyl schopnej do sebe [...] zápis od doktorů že pacient po medikaci klidnější, spolupráce zlepšená, avšak dostavily se symptomy EPS. [...] Ale já musím říct že mi to pomohlo. [...] Není to úplně černobílý."
Translated from Czech into English:
    "Then they gave me injection and I do not recall several days after the injection [...] I was then unable to walk, talk; when I had to eat, I was unable to put into myself [...; food?] record from the doctors that the patient is calmer after the medication, cooperation improved, but there are extrapyramidal symptoms" [...] But I have to say it helped. [...] It is not entirely black and white."
The injection must have been one of zuclopenthixol acetate, to match the above quoted medical record.
A reservation: The above described response to medication is to a combination of Cisordinol Acutard and levomepromazine, not Cisordinol Acutard alone.
See also A review of Jindřich Jašík's Journey out of Schizophrenia.

## Adverse event reports

I do not know of an online database reporting adverse events of psychiatric drugs. This section will therefore be very unsatisfactory and anecdotal.
Reported adverse events:
* In Jindřich Jašík; see The case of Jindřich Jašík.
* An anonymous report about zuclopenthixol decanoate now available on the talk page of the English Wikipedia: W: Talk:Zuclopenthixol, 203.59.200.161, 29 June 2007 (UTC), diff comparison. However, this is not directly applicable since it is about decanoate.
* Second anonymous report on the talk page of the English Wikipedia: W: Talk:Zuclopenthixol, 185.69.145.23. It is not clear in that report which variant it refers to.
Another source of reports can be obtained by searching "zuclopenthixol" and "Clopixol" in site:madinamerica.com via Google. The search does find some stories but none specifically on the acetate variant.

## Adverse effects

Adverse effects (also known as side effects) are provided in the leaflets in the further reading.