Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals

Flanagan, Robert J.; Lally, John; Gee, Siobhan; Lyon, Ray; Every‐Palmer, Susanna

doi:10.1093/bmb/ldaa024

Cited by 36 publications

(33 citation statements)

References 85 publications

(89 reference statements)

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“…This might be explained by the fact that clozapine requires a strict initiation and titration protocol for administration, thus making it difficult to be initiated within the first 72 h after involuntary hospital admission for compulsory treatment. 36 In contrast, data on community treatment orders, as a form of compulsory treatment of individuals diagnosed with a mental illness in the community, show that first-generation LAI antipsychotics and clozapine are associated with antipsychotic polypharmacy, and oral second-generation antipsychotics and LAI risperidone are both associated with prescription of high-dose antipsychotics. 37 …”

Section: Discussionmentioning

confidence: 99%

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

et al. 2021

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Background Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. Aims We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. Method This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. Results Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. Conclusions A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

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Section: Discussionmentioning

confidence: 99%

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

et al. 2021

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“…neutropenia, myocarditis and constipation). 13 Second, it interacts with many other drugs. 13 Both of these factors may worsen an acute or chronic physical health problem.…”

Section: Discussionmentioning

confidence: 99%

Intramuscular clozapine in the acute medical hospital: Experiences from a liaison psychiatry team

Gee

McMullen

Wyke

et al. 2021

SAGE Open Medical Case Reports

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We present two cases demonstrating safe and effective use of intramuscular clozapine for patients who are physically unwell in acute medical care settings. Both patients described were admitted to inpatient medical care units and required treatment with clozapine to control their psychotic symptoms, but were unable or unwilling to take oral clozapine. We describe the use of intramuscular clozapine in these patients, including dosing decisions, administration routes and frequency of dosing. Outcome was measured by a reduction in psychotic symptoms, sufficient to allow treatment for physical illness. Both patients successfully received intramuscular clozapine, allowing timely treatment of their physical health conditions. There were no adverse events, and significant improvement in their mental health presentations was achieved. We have shown that intramuscular clozapine is a safe and effective treatment for patients with serious mental health illness in the acute medical hospital.

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“…2–5 Sialorrhea and dysphagia with clozapine may result in choking and aspiration pneumonia. 6 Clozapine-induced gastrointestinal hypomotility (CIGH) may cause constipation, ileus, bowel obstruction, aspiration pneumonia, peritonitis, life-changing surgery and even death. 7 Various forms of colitis in patients taking clozapine, apparently without constipation, have also been reported.…”

Section: Adverse Drug Reactionsmentioning

confidence: 99%

Clozapine-induced gastrointestinal hypomotility: presenting features and outcomes, UK pharmacovigilance reports, 1992–2017

Handley

Every‐Palmer

Ismail³

et al. 2022

Br J Psychiatry

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Background Clozapine-induced gastrointestinal hypomotility (CIGH) affects some 75% of patients treated with clozapine. Aims To document the incidence of potentially harmful CIGH in the UK. Method We studied spontaneous UK pharmacovigilance reports recorded as clozapine-related gastrointestinal adverse drug reactions, 1992–2017. Results There were 527 patients reported with potentially harmful CIGH; 33% (n = 172) died. Deaths averaged 1 per year 1992–1999, 5 per year 2000–2009 and 15 per year 2010–2017. Those who died were older (median 52 years v. 49 years) and had been prescribed clozapine for longer than those who recovered (median 11.3 years v. 4.8 years), but there was no difference in prescribed dose. Within the first 4 years of clozapine treatment, there were 169 reports of CIGH, of which 3% (n = 5) were fatal. At 10–14 years there were 63 reports of CIGH, of which 25% (n = 16) were fatal. Among the deaths, males were younger (median 51, range 22–89 v. median 57, range 24–89 years) with higher clozapine doses (median 450, range 100–900 v. median 300, range 12.5–800 mg/d) than females. In non-fatal CIGH, surgery was the most frequent outcome (n = 92). The procedures included appendectomy, ileostomy, total/partial colectomy, colostomy/stoma and proctosigmoidectomy. Clozapine dosage was reduced in 6 patients, stopped and restarted in 23, ‘continued’ in 6 and discontinued permanently in at least 76 patients. Conclusions The risk of serious morbidity/mortality from CIGH is substantial. The need to actively monitor bowel function and give laxatives to patients treated with clozapine is clear.

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Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals

Cited by 36 publications

References 85 publications

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

Intramuscular clozapine in the acute medical hospital: Experiences from a liaison psychiatry team

Clozapine-induced gastrointestinal hypomotility: presenting features and outcomes, UK pharmacovigilance reports, 1992–2017

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