The assertive approach to clozapine: nasogastric administration

Abstract

Five of the most extremely ill patients with treatment-resistant schizophrenia were established and/or maintained on clozapine, resulting in improvements to their mental state; incidents were reduced, segregation was terminated and progression to less restrictive environments was achieved.Clinical implicationsDespite being underutilised and rarely enforced, in extreme circumstances, an assertive approach to clozapine can be justified. Nasogastric clozapine can be safely delivered and the approach itself, rather than actual nasogastric administration, may be enough to help establish and maintain patients with treatment-resistant schizophrenia on the most effective treatment.Declaration of interestE.S. has received speaker fees from Jansen Pharmaceuticals and Novartis.

A retrospective study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis

“…Nevertheless, the intramuscular route remains well-established in clinical practice and avoids the considerably more invasive and distressing nature of nasogastric administration and its greater resource requirements. 8 Although our sample is too small to draw any firm conclusions, our findings may justify safely persisting with intramuscular clozapine to achieve transition to oral formulation, despite a prolonged refusal of oral treatment. Nevertheless, individual-based decisions are paramount to ensure the best interest of every patient.…”

“…Nevertheless, the intramuscular route remains well-established in clinical practice and avoids the considerably more invasive and distressing nature of nasogastric administration and its greater resource requirements. 8…”

“…However, since clozapine is not available as a long-acting injection, an unwillingness to take the oral form of clozapine has hitherto precluded clozapine treatment. Although compulsory administration of medication is not uncommon in psychiatric care, this is rarely used with clozapine treatment, with only a few facilities worldwide reporting the use of nasogastric 8 and intramuscular clozapine. [9][10][11][12][13] In this study, we present our 3-year experience with short-acting intramuscular clozapine in the South London and Maudsley NHS Foundation Trust (SLaM).…”

Clozapine rechallenge and initiation despite neutropenia- a practical, step-by-step guide

“…It is very helpful to acknowledge this in the plan itself. We have also had experience of the use of enforced naso-gastric clozapine [2] and with clozapine given after severe physical health comorbidities [3]; whilst clear and informed clinical decision making is essential, careful thought must also be given to the team and institutional factors that can facilitate or interfere with these sorts of intrusive and unusual interventions [4].…”

“…However, some may respond much later in treatment, although frequently sub-optimally, but even a small improvement may be sufficient to improve quality of life and function in groups as severely affected and restricted as ours [32,33]. In these cases there may remain the possibility of sufficient improvement to achieve management of violence [34] and or discontinuation of seclusion [2] if not full symptom control. Rechallenge should not be discounted in cases where the previous response was less than good, relatively brief or when plasma levels indicate room for dose escalation [31,33,35]; however, there will be increased uncertainty.…”