Addressing clozapine under-prescribing and barriers to initiation

Leung, Jonathan G.; Cusimano, Joseph; Gannon, Jessica; Milgrom, Olga; Valcourt, Stephanie C.; Stoklosa, Joseph; Kemp, Michael T.; Olsufka, William; Vickery, P. Brittany; Nichols, Stephanie D.; Crouse, Ericka L. Breden; Paxos, Chris; Johnson, Emily; Palmer, Brian A.

doi:10.1097/yic.0000000000000269

Cited by 13 publications

(30 citation statements)

References 30 publications

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“…Access to expertise, such as a “hub and spoke” model, may also help clinicians with clozapine management 3 . This is supported by evidence that most clinicians view clozapine prescribing as a burden 39 . Reducing the perceived cumbersome nature of clozapine monitoring by minimising the degree of physical health monitoring (whilst maintaining safety standards) through evidence-based guidelines alongside use of POC testing could reduce barriers to clozapine use, improve patient satisfaction and overall increase clozapine utilisation 40 .…”

Section: Discussionmentioning

confidence: 89%

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

Oloyede¹,

Blackman²,

Mantell³

et al. 2023

Schizophr

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Clozapine is the most effective medication for treatment-resistant psychosis, but evidence points to substantial underuse, especially within early intervention psychosis (EIP) services. We explored clinicians’ views on perceived barriers and facilitators to offering patients clozapine within EIP services. A cross-sectional survey was distributed electronically to clinicians practising in EIP services across England. A mixed methods approach was used to assess barriers to clozapine, and attitudes and opinions concerning clozapine underutilisation. Based on the barriers identified in the literature, clinicians were asked to rate each one (scale:1-7) based on importance, with a higher score indicating higher importance. Clinicians were also asked open-ended questions on barriers to clozapine and how access can be improved in EIP services. Quantitative data were analysed using descriptive and inferential statistics, and qualitative responses were analysed thematically. One hundred and nineteen EIP clinicians from 35 services in England completed the survey. In total, 37% (n = 45) of clinicians perceived that clozapine was under-prescribed in their EIP service. The most important barrier to utilising clozapine were patient concerns with side effects, followed by monitoring requirements and clinician concerns with side effects. Thematic analysis identified 17 perceived barriers, which were grouped into three major themes: administrative (5 subthemes), clinician-related (6 subthemes), and patient-related (6 subthemes). Perceived facilitators to improving clozapine use were greater training, improved resources, and optimised monitoring. The main barriers to clozapine in EIP services, as identified by clinicians, are patient concerns regarding side effects and monitoring requirements. Identified facilitators for improved clozapine use include clinician training, improved resources, guidelines, and point-of-care testing.

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Section: Discussionmentioning

confidence: 89%

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

Oloyede¹,

Blackman²,

Mantell³

et al. 2023

Schizophr

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“…The most common facilitators to increase clozapine prescription and utilization included providing clozapine education and support through dedicated clozapine clinics and implementing POC testing to facilitate monitoring. Multiple articles recommended creating and utilizing standardized clozapine clinics, including during residency, to help improve prescriber knowledge and training regarding clozapine management [3,17,18,20,22–24] . Ismail et al [20] and Leung et al [22] mentioned utilizing a multidisciplinary team, including pharmacists in clozapine clinics to improve clozapine management; support prescribers; and assist with monitoring.…”

Section: Resultsmentioning

confidence: 99%

“…Moody and Eatmon [17] and Rubio and Kane [9] also advised designating an administrative contact and making administrative partnerships to assist with administrative tasks. Increasing prescriber education and training through continued medical education can help address adverse events, side effect monitoring, and prescribing logistics [9,17,22,23] . Furthermore, improving clinician education regarding early identification of eligible patients and care management after clozapine initiation may encourage and increase clozapine prescription [19] .…”

Section: Resultsmentioning

confidence: 99%

Clozapine prescribing barriers in the management of treatment-resistant schizophrenia

et al. 2021

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Background:Treatment-resistant schizophrenia is prevalent and difficult to manage, as patients fail multiple antipsychotic trials before being considered as treatment-resistant. Currently clozapine is the only Food and Drug Administration-approved pharmacotherapy for treatment-resistant schizophrenia but remains under-prescribed. The purpose of this study is to investigate recent literature on clozapine in order to identify barriers to prescribing clozapine and categorize the recommended solutions.Methods:We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using free text and the medical subject headings, we searched MEDLINE/PubMed electronic bibliographic database from 2017 until 2020. Eligible studies included peer-reviewed English language articles with multiple methodologies aiming to identify clozapine barriers in treatment-resistant schizophrenia. We used search terms combining clozapine AND treatment OR treatment-resistant schizophrenia AND barriers AND prescribing OR prescription OR prescriber. We merged search results in a citation manager software, removed duplicates, and screened the remaining articles based on the study eligibility criteria.Results:We retrieved 123 studies, however, only 10 articles exclusively met the study inclusion criteria for full text review. These studies represented 20 countries; 6 were exclusively conducted in the US. The top barriers delineated by the studies include: providers’ lack of knowledge and training (n = 7), concern about side effects (n = 8), and poor adherence (n = 7). All studies described more than 1 barrier. Other barriers included prescriber-perceived barriers (n = 4), administrative barriers (n = 5), and other healthcare systems-related barriers (n = 3). Top recommendations to overcome clozapine prescription barriers included improving prescriber clozapine education/training, utilizing interdisciplinary teams and providing integrated care via clozapine clinics, and simplifying blood test monitoring.Conclusion:Clozapine remains under-prescribed for patients with treatment-resistant schizophrenia due to multiple barriers related to the individual prescriber, system of care, and technology. It is recommended that by improving prescriber knowledge and training, use of integrated care, and use of technology that can enable continuous, real-time blood test monitoring, these barriers may be overcome.

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“…Despite the importance of this interaction, knowledge gaps exist surrounding the effect or lack of effect on clozapine from smoking or use of noncombustible nicotine products. A survey 12 of 184 psychiatric prescribers found only 20.4% correctly answered that chewing tobacco cessation would not affect clozapine concentrations. Unlike smoking cigarettes, which induces CYP450 1A2 through the formation of PAH, the use of ENDS, nicotine replacement therapy, chewing tobacco, and snuff does not have this effect.…”

Section: Discussionmentioning

confidence: 99%

Fluctuation between cigarette smoking and use of electronic nicotine delivery systems: Impact on clozapine concentrations and clinical effect

Montville

Lindsey

Leung³

2021

Mental Health Clinician

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Unlike with smoking cigarettes, electronic nicotine delivery systems do not cause CYP450 1A2 induction as there is a lack of combustion and polycyclic aromatic hydrocarbon production. Changing to the use of an electronic nicotine delivery system from cigarettes can result in the deinduction of CYP450 1A2 and the increase of certain medication serum concentrations, including clozapine. A case is reported in which the switch from smoking to an electronic nicotine delivery system resulted in increased clozapine serum concentration and constipation, necessitating pharmacologic management. The patient ultimately transitioned back to cigarettes, which resulted in the emergence of psychiatric symptoms. An evaluation of longitudinal serum concentrations and clinical correlation is provided. It is important that patients and health care professionals have knowledge not only about the impact of smoking cigarettes on clozapine metabolism, but also the effects of switching to or from an electronic nicotine delivery system.

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Addressing clozapine under-prescribing and barriers to initiation

Cited by 13 publications

References 30 publications

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

Clozapine prescribing barriers in the management of treatment-resistant schizophrenia

Fluctuation between cigarette smoking and use of electronic nicotine delivery systems: Impact on clozapine concentrations and clinical effect

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