Continuation of clozapine during chemotherapy and a stem cell transplant

Abstract

Cancer incidence rates in the UK have increased by more than a third over the last four decades, so the likelihood of requiring concurrent chemotherapy and clozapine is increasing. In this situation clinicians are faced with a clinical conundrum: to stop clozapine and risk a psychotic relapse, or to continue clozapine and risk a potentially fatal agranulocytosis. This case report describes how a multidisciplinary team (MDT) worked together to balance the mental and physical health needs of a patient.

Feasibility of myelosuppressive chemotherapy in psychiatric patients on clozapine: A systematic review of the literature

“…In only one case where clozapine was restarted was it stopped again (and substituted with olanzapine) due to recurrent severe neutropenia, and this resulted in only partial symptom control . Conversely, of the 14 cases where clozapine was continued, only one described the emergence of psychotic symptoms during chemotherapy which were able to be managed with non‐pharmacologic support from the patient's community psychiatric nurse, with whom she was said to have excellent rapport . Five described stable mental state, and psychiatric outcome was not described in the remaining eight cases.…”

“…The only clinical complication of neutropenia encountered in a patient remaining on concomitant clozapine was one case of coagulase‐negative Staphylococcal bacteremia. G‐CSF prophylaxis was in this case contraindicated by the patient's primary amyloidosis . Nine cases described the administration of G‐CSF to augment counts .…”

“…Furthermore, in all but one case, the employment of alternative antipsychotics was unsuccessful in controlling symptoms, prompting the re‐introduction of clozapine despite reservations by the clinicians concerned. However, the documented neutropenia‐related complications associated with remaining on clozapine were limited to one case of bacteremia, which responded to antibiotic therapy . Additionally, it should be acknowledged that chemotherapy itself is a risk factor for psychiatric decompensation, with one patient being described as reduced to psychotic mutism despite being maintained on clozapine during their treatment with chemotherapy …”

“…However, the documented neutropenia‐related complications associated with remaining on clozapine were limited to one case of bacteremia, which responded to antibiotic therapy . Additionally, it should be acknowledged that chemotherapy itself is a risk factor for psychiatric decompensation, with one patient being described as reduced to psychotic mutism despite being maintained on clozapine during their treatment with chemotherapy …”

“…One report did not specify the age or gender of the patient, 46 and another did not specify age. 31 Nineteen patients had a diagnosis of schizophrenia, 16,18,19,[21][22][23][24][25][26][27][28][29][30]32,34,35,38,41,43 three had schizoaffective disorder, 20,31,40 three had BPD, 37,39,44 one was described only as having "psychosis", 42 and one was without a formal psychiatric diagnosis. 36 The median duration of psychiatric illness was 24.5 years.…”