Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents

Singh, Balwinder; Hughes, A.J.; Roerig, James L.

doi:10.1007/s40596-019-01134-7

Cited by 18 publications

(43 citation statements)

References 20 publications

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“…However, despite this strong recommendation, clozapine is underutilized in this setting [ 44 – 46 ], and many patients initiate clozapine treatment after delays associated with trials of antipsychotic polypharmacy [ 27 , 47 , 48 ]. This may be due to the side-effect profile of clozapine, the monitoring requirements associated with its use, and a lack of prescribing experience [ 49 , 50 ]. A systematic review that investigated facilitators of guideline adherence in treating TRS identified institutional directives/audits, integrated clozapine clinics, facilitated monitoring, interaction with experts, educational programs, and distribution of educational material as effective strategies for increasing access to clozapine [ 51 ].…”

Section: Introductionmentioning

confidence: 99%

A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia

et al. 2022

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Section: Introductionmentioning

confidence: 99%

A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia

et al. 2022

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“…Singh et al [3] surveyed 165 US resident psychiatrists only from Accreditation Counsel for Graduate Medical Education-accredited programs. They found that about 41% of residents felt comfortable prescribing clozapine, while only 18% felt very comfortable despite having clozapine-eligible patients [3] . Additionally, 63% of residents had prescribed clozapine regardless of training level, suggesting inadequate clozapine exposure during residency [3] .…”

Section: Resultsmentioning

confidence: 99%

“…It is estimated that 30% of patients with schizophrenia are considered treatment-resistant [2] . Clozapine remains the gold standard pharmacotherapy for treatment-resistant schizophrenia but is under-utilized [3] . Treatment-resistant schizophrenia is defined as insufficient treatment response after 2 adequate trials of different antipsychotics, once medication adherence is ensured [2] .…”

Section: Introductionmentioning

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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“…For these patients, initiation of clozapine is recommended at the earliest possible opportunity (McGorry et al, 2005; NICE, 2014) and there is evidence for its superior efficacy in this difficult-to-treat population compared with other pharmacological therapies (Siskind et al, 2016). However, clozapine remains underutilized due, in part, to the risk of unpredictable and often fatal adverse drug reactions, such as myocarditis (Dvalishvili et al, 2021; Farooq et al, 2019; Singh et al, 2020).…”

Section: Introductionmentioning

confidence: 99%

Clozapine-induced myocarditis and patient outcomes after drug rechallenge following myocarditis: a systematic case review

Richardson

Greenway

Bousman

2021

Preprint

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Clozapine is underutilized due, in part, to concerns about rare but severe adverse drug reactions, including cardiac inflammation and injury (myocarditis). Risk factors for clozapine induced myocarditis are limited and predictors for the successful rechallenge of clozapine after an episode of myocarditis are even more poorly understood. We conducted a systematic review, in accordance with the PRISMA recommendation, of published case reports to describe demographic and clinical characteristics of patients with clozapine induced myocarditis and identify potential markers of clozapine rechallenge success. A total of 180 cases from 88 articles were evaluated. Male cases of clozapine associated myocarditis were more frequently reported than female cases by a ratio of 6:1. Less than half of patients reported the presence of chest pain (35%) or flu like symptoms (43%) but increases in troponin or C-reactive protein were present in 87% of cases. Clozapine rechallenge was carried out in 34 (2 female) cases, with successful reintroduction in 22 (2 female) cases (64.7%). Only chest pain during the initial trial was found to be significantly associated with rechallenge success (odds ratio = 6.87, 95% CI = 1.17, 40.3). Standardized reporting of clozapine induced myocarditis cases is needed to facilitate the identification of factors associated with successful rechallenge.

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Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents

Cited by 18 publications

References 20 publications

A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia

A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia

Clozapine prescribing barriers in the management of treatment-resistant schizophrenia

Clozapine-induced myocarditis and patient outcomes after drug rechallenge following myocarditis: a systematic case review

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