The physical health and side-effect monitoring of patients prescribed clozapine: data from a clinical audit conducted in UK mental health services

Abstract

Background: In addition to mandatory haematological monitoring, treatment guidelines recommend routine monitoring of adverse effects and physical health in patients prescribed clozapine. Methods: NHS trusts/healthcare organisations participated in a clinical audit in the context of a UK quality improvement programme addressing clozapine-prescribing practice. Results: Data relating to 6948 adult patients prescribed clozapine were submitted by 63 NHS trusts/healthcare organisations. Of 481 patients treated with clozapine for up to 18 weeks, there was documented pretreatment screening of blood pressure, heart rate and ECG in at least 90%, and body weight, plasma lipids, plasma glucose/glycated haemoglobin (HbA1c) and physical examination in approximately 80%. During the first 2 weeks of clozapine treatment there was documented daily measurement of both heart rate and blood pressure in 82% and body temperature in 77%. In a subsample of 411 patients, of the 72% who had weekly side-effect assessments documented in the first month of treatment, a structured assessment tool had been used in 29%. Treatment monitoring up to 18 weeks included an ECG in 90%, C-reactive protein (CRP) or creatine kinase in 42%, and troponin or B-type natriuretic peptide (BNP) in 29%. In the 5908 patients prescribed clozapine for at least 1 year, blood pressure and body weight/body mass index were documented in at least 80%, plasma lipids in 78% and plasma glucose in 73%, with an ECG in 55%. Two-thirds were prescribed medication to manage side effects of clozapine and one third of those with a diagnosis of schizophrenia were prescribed a second antipsychotic medication. Conclusion: The findings suggest that for most patients treated with clozapine in UK mental health services, physical health screening and side-effect monitoring follow recommended practice, but there was limited use of structured side-effect assessment tools. Monitoring for clozapine-induced myocarditis during the early risk period using markers of inflammation such as CRP, and cardiac damage such as troponin and BNP, was less consistent. This may partly reflect the variation in guideline recommendations for monitoring for myocarditis and partly the selected use of such tests when prompted by cardiac symptoms. The relatively common coprescription of medications for the majority of people on longer-term clozapine treatment may well further increase side-effect burden and physical health risks, reinforcing the need for continuing systematic monitoring.

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

“…However, several potentially life-threatening side effects are not detected by patient-compiled rating scales. An audit conducted in UK mental health services found that patient-compiled rating scales may be underutilized [ 111 ].…”

Mapping the Knowledge of Antipsychotics-Induced Sudden Cardiac Death: A Scientometric Analysis in CiteSpace and VOSviewer

“…Among the literature most closely related to this cluster, Ronaldson et al ( 18 ), Curto et al ( 19 ), Bellissima et al ( 25 ), Knoph et al ( 26 ), and Ronaldson et al ( 27 ) have the highest citation frequency and can represent the research base in this field. The top five cited studies, Barnes et al ( 28 ), Chopra et al ( 29 ), Kanniah et al ( 30 ), Brazile et al ( 31 ), and Anıl Yağcıoğlu et al ( 32 ), can represent the research frontiers in this field ( Table 3 ).…”

“…Current monitoring protocols include slow titration, close cardiac monitoring, and reduction of polypharmacy ( 54 ). In the early risk period of clozapine-induced myocarditis, monitoring results using inflammatory markers, such as C-reactive protein, and cardiac damage indicators troponin and brain natriuretic peptide are inconsistent ( 28 ). Therefore, investigators should not focus on the need to discontinue clozapine, but rather to provide more effective recommendations for monitoring.…”

Prescribing clozapine in the UK: Quality improvement issues identified by clinical audit

“…The tool was designed to capture information from the clinical records related to clinical performance against seven evidence-based practice standards, which had been derived from the NICE Clinical Guideline CG178, ‘ Psychosis and Schizophrenia in Adults: Prevention and Management ’ ( NICE, 2014 ) and ‘ The Maudsley Prescribing Guidelines in Psychiatry ’ (2018), 13th edition. Five of these practice standards referred to medication review and monitoring of physical health and adverse effects, and performance against these standards has been reported elsewhere ( Barnes et al, 2020a ). Another practice standard concerned the ‘off-label’ prescription of clozapine, and the remaining standard addressed the management of a change in tobacco smoking habit: ‘For patients started on clozapine as inpatients, there should be consideration of the implications for dosage of any change in smoking status on discharge’.…”

“…This article reports on the findings of two clinical audits, conducted in 2019 and 2021, as part of the POMH QI programme on the use of clozapine (a receptor antagonist: D2, 5-HT2, NE alpha-2) in UK mental health services (Prescribing Observatory for Mental Health, 2019Health, , 2021. The methodology of the 2019 audit has been reported previously (Barnes et al, 2020a). Analysis of the data collected in both the audits identified possible areas for improvement in relation to the antipsychotic medication regimens prescribed before starting clozapine, the management of clozapine treatment during a change in smoking status and the inclusion of clozapine in a community patient's Summary Care Record (SCR).…”