Clozapine is a second-generation antipsychotic often reserved for use in treatment resistant schizophrenia.  Clozapine is associated with agranulocytosis which requires strict lab monitoring and reporting to an online Risk Evaluation and Mitigation Strategy website.  Strict lab monitoring requirements and heavy side effect profiles may limit clozapine usage, despite its potential benefit and effectiveness.  As clozapine remains a gold-standard for treatment-resistant schizophrenia, it is imperative that psychiatric pharmacists understand all aspects of clozapine-related care.  To serve as advocates for appropriate clozapine use and to serve as information resources for providers and patients, the following questions will need to be answered properly.

  • How should clozapine be appropriately monitored and how do I report or check lab values?1-3
  • How do I manage clozapine-induced blood dyscrasias?1,4-9
  • Aside from blood dyscrasias, what are the most common and important clozapine-induced adverse effects to educate on and monitor for?10-14
  • Where can I find a summary of important clozapine awareness information?15

References

  1. Clozapine  Risk Evaluation and Mitigation Stratigies (REMS) [Weblink].
  2. Fact Sheet for Outpatient Pharmacies  [Weblink]
  3. How to Start Clozapine and Monitor Patients Fact Sheet [Weblink]
  4. Management and Prevention of Agranulocytosis in Patients Receiving Clozapine. Ment Health Clin. 2013;3(3):139-143. DOI: 10.9740/mhc.n166825.
  5. Kelly D. Hematologic Issues and Antipsychotic Medications: Overview and Management. Presented at the CPNP Annual Meeting (2016).  Presentation covers blood dyscrasias and hematologic issues with antipsychotic treatment and then focus on issues related to clozapine and the new guidelines implemented.[Weblink]
  6. Clinical Pearl from the CPNP 2015 Annual Meeting:  Treatment Options for Clozapine-Induced Dyscrasias [Weblink]
  7. Deardorff OG, Ripperger KD. Clozapine-induced neutropenia: A review of lithium and other currently available options. Ment Health Clin. 2012;2(1):5- 7. DOI: 10.9740/mhc.n110673.
  8. J de With SA, Pulit SL, Staal WG, Kahn RS, Ophoff RA.  More than 25 years of genetic studies of clozapine-induced agranulocytosis. The Pharmacogenomics Journal (2017) 17, 304–311. [Weblink]
  9. Myles N, Myles H, Clark SR, Bird R, Siskind D. Use of granulocyte-colony stimulating factor to prevent recurrent clozapine-induced neutropenia on drug rechallenge: A systematic review of the literature and clinical recommendations. Aust N Z J Psychiatry. 2017;51(10):980- 989. DOI: 10.1177/0004867417720516. PubMed PMID: 28747065.
  10. Citrome L, McEvoy J, Saklad S. A Guide to the Management of Clozapine-Related Tolerability and Safety Concerns. Clin Schizophr Relat Psychoses. 2016 Jul 25. [Weblink]
  11. Fitzsimons J, Berk M, Lambert T, Bourin M, Dodd S. A review of clozapine safety. Expert Opin Drug Saf. 2005;4(4):731-44. DOI: 10.1517/14740338.4.4.731. PubMed PMID: 16011451.
  12. Curto M, Giardi N, Lionetto L et al.  Systemic Review of Clozapine Cardiotoxicity.  Curr Psychiatry Rep (2016) 18: 68. [Pubmed]
  13. Whitney Z, Procyshyn RM, Fredrikson DH, Barr AM. Treatment of clozapine-associated weight gain: a systematic review. Eur J Clin Pharmacol. 2015;71(4):389-401. DOI: 10.1007/s00228-015-1807-1. PubMed PMID: 25627831.
  14. Fowler JA. Clozapine-induced gastrointestinal hypomotility: More than just constipation. Ment Health Clin. 2011;1(5):92- 93. DOI: 10.9740/mhc.n87491.
  15. Hieber R. MHC Clozapine Tool Box. Ment Health Clin [Internet]. 2011;1(5):20. Available from: http://cpnp.org/resource/mhc/2011/11/mhc-clozapine-tool-box