Consensus statement on the use of clozapine during the COVID-19 pandemic

Siskind, Dan; Honer, William G.; Clark, Scott; Correll, Christoph U.; Hasan, Alkomiet; Howes, Oliver; Kane, John M.; Kelly, Deanna L.; Laitman, Robert; Lee, Jimmy; MacCabe, James H.; Myles, Nick; Nielsen, Jimmi; Schulte, Peter F.J.; Taylor, David; Verdoux, Hélène; Wheeler, Amanda; Freudenreich, Oliver

doi:10.1503/jpn.200061

Cited by 126 publications

(157 citation statements)

References 11 publications

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“…30 Recently, a consensus statement has been published stating that, if certain criteria are met, monitoring ANC values may occur every 3 months. 31 However, it may be advisable to retain usual laboratory protocols for athletes on clozapine, especially those in endurance sports or with relative energy deficiency in sport (RED-S), as these groups may have altered immune function 32 or lower total white cell and ANC values at baseline. 33 Importantly, the statement also notes that patients with COVID-19 might be at risk of clozapine toxicity.…”

Section: Medications For Bipolar and Psychotic Disordersmentioning

confidence: 99%

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Bindra²,

et al. 2020

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Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.

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Section: Medications For Bipolar and Psychotic Disordersmentioning

confidence: 99%

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Bindra²,

et al. 2020

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“…At the start of the pandemic, an international consensus statement was drafted to provide guidance on how to continue treating patients with this life-saving medication. 3 Recommendation 3 of these guidelines warns clinicians of possible clozapine toxicity in the setting of severe respiratory illnesses such as COVID-19. Recently it has been recognized that severe systemic inflammation can increase clozapine levels, in part due to cytokinemediated inhibition of CYP1A2.…”

mentioning

confidence: 99%

“…4 Therapeutic drug monitoring and consideration of dose reduction is generally recommended under such conditions. 3 Levels in the 200-to 450-ng/mL range are associated with improved responses, while levels above 1000 ng/mL are associated with toxicity. 5 Consult psychiatrists should therefore be careful to monitor clozapine levels and signs of toxicity in patients diagnosed with COVID-19, while remaining vigilant for potentially life-threatening side effects necessitating a temporary dose reduction.…”

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confidence: 99%

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Clozapine Toxicity in the Setting of COVID-19

Dotson

Hartvigsen

Wesner³

et al. 2020

Psychosomatics

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“…Although it is likely to be challenging to commence clozapine therapy during the COVID-19 pandemic, current advice is to continue clozapine in acute COVID-19 illness, 8 and in community patients without COVID-19 infection already prescribed the medication. 9 , 10 There are provisional guidelines on the rationale for continuing or discontinuing clozapine 8 and data are emerging on successful continuation of clozapine in the community during the COVID-19 pandemic. 11 …”

Section: Introductionmentioning

confidence: 99%

Clozapine prescribing in COVID-19 positive medical inpatients: a case series

Butler

Bano

Calcia

et al. 2020

Therapeutic Advances in Psychopharmacology

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There is both uncertainty regarding the safety of clozapine in COVID-19 patients owing to limited published data and a lack of consensus on continuing clozapine in patients with severe respiratory infections. COVID-19 is known to induce an acute immune response which can affect haematological parameters associated with clozapine monitoring, and systemic infection may reduce clozapine clearance. Clozapine, which has been associated with worse outcomes in some pneumonias, may in theory worsen outcomes in COVID-19. Despite these concerns, there are some data to indicate it is safe to continue clozapine in COVID-19 infection. In this retrospective case series, we describe our experiences of clozapine prescribing and disease progression of eight SARS-CoV-2 positive patients on medical wards in a major London teaching hospital. In four cases clozapine was stopped during the hospital admission. A COVID-19 pneumonia developed in four patients: three of these required intensive care unit admission for an average of 34 days. At the time of writing, three patients had died (two directly from COVID-19 pneumonia), two remained in general hospital wards, two were recovering in the community and one had been transferred to an inpatient psychiatric hospital. Follow-up length varied but in each case was not more than 104 days. Delirium was the most common adverse neuropsychiatric event, and in one case a relapse of psychosis occurred after cessation of clozapine. This retrospective case series illustrates the safe use of clozapine during COVID-19 infection. Our experiences suggest that consideration should be made to continuing clozapine even in those most unwell with COVID-19. We also identify areas which require larger scale hypothesis-testing research.

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Consensus statement on the use of clozapine during the COVID-19 pandemic

Cited by 126 publications

References 11 publications

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Clozapine Toxicity in the Setting of COVID-19

Clozapine prescribing in COVID-19 positive medical inpatients: a case series

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