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This is dr. nicholas hatcher and psychopharmacologic and psychotherapeutic here is a reminder of where we are in the series now that we’ve considered the various this lecture will emphasize a specialized topic regarding the psychopharmacologic principles of psychosis treatment clozapine treatment resistance schizophrenia
Affects 20 to 30 percent of all patients diagnosed with schizophrenia clozapine is a potential option for that patient population clozapine was initially shown to be more effective than chlorpromazine the proteotypical first generation antipsychotic it then showed advantage over several first generation antipsychotics
In various trials the cutlass ii study found that patients failing to respond to two or more antipsychotics responded well to clozapine the catie trial revealed effectiveness over quetiapine has been shown to reduce mortality over other antipsychotic agents including first generation antipsychotics risperidone
And quetiapine antipsychotic with several considerations the most important of which is that you must check a baseline complete blood count or cbc in order to ensure that white blood cells are greater than 3.5 and the absolute neutrophil count is greater than this must be monitored on a frequent basis
A baseline ekg is also required to ensure that the qtc is less than 500 milliseconds otherwise it is best to re-evaluate after the removal of other qtc prolonging medications clozapine is a medication that must be titrated slowly it takes several weeks to get to the optimum dose it is important to know also that if a
Patient stops clozapine for greater than 48 hours it must be re-titrated in consecutive slides i provided you with additional information on monitoring clozapine here i’ve listed monitoring considerations for clozapine one in 30 or 3.8 percent of patients develop mild neutropenia one in 100 or 0.9 percent of patients
Develop severe neutropenia in order to monitor for this it’s generally recommended to do a cbc every week for six weeks every two weeks then for six months then monthly for six months absolute neutrophil count drops below patients on clozapine are three times more likely to develop myocarditis than neutropenia the
Classical presentation is a patient on clozapine presents with chest pain dyspnea flu-like symptoms with troponinemia and an increase in c-reactive protein when this is the case stop clozapine will be discussed in the following slide and send the patient to the hospital for an ekg eosinophilia may be noted on the cbc it
May indicate any of the following myocarditis when it’s combined with an elevated troponin or c-reactive protein nephritis when it’s combined serum creatinine pancreatitis when it’s combined with an elevated lipase or hepatitis when there is combined derangement of lfts it’s important here to stop clozapine
If there’s any significant finding and treat the underlying issue sialorrhea is a common issue that here it’s important to monitor for breath sounds cough dyspnea any presence of fever respiratory i’ve listed here three common management constipation can be a significant issue for patients on clozapine in fact they
Can develop a fatal alias while on clozapine it’s important to monitor bowel sounds bowel patterns and the presence of nausea or vomiting to help with this try to decrease any systemic anticholinergic activity look at their other medications to see if they’re on any other anticholinergic drugs to prevent
This it may help to prophylactically treat the patient with docusate and biscodyl or peg maintain a high fiber diet and increase fluid intake if this is ineffective i have listed some medications here that have shown some benefit in helping abrupt discontinuation of clozapine may result in cholinergic rebounds this
Causes the symptoms of delirium nightmares and diarrhea it is recommended to give benztropine one milligram for every 50 milligrams of clozapine in the non-smoker smoker as i mentioned before if clozapine clozapine seizures is another consideration orthostatic hypotension is much more common so ask the
Question did they just syncopize due to orthostatic hypotension or was it truly a seizure if concerned depakote is a better option than lamictal because it covers both generalized and better than phenytoin and carbamazepine here i’ve listed a graph showing clozapine levels there are three key reasons to check
Clozapine levels number one if there’s a poor response at 600 milligrams number two if there’s for downloadable content such as written notes powerpoint slides and more related you can also support my goal of continuing to provide new content through patreon where becoming a patron will provide you with access
To downloadable content as i create new content thank you for your support here are my references for this presentation thank you for watching.
Transcribed from video
6.1.1 – Psychosis – Palliation – Clozapine By Nicholas Hatcher
