Clozapine clinical vignette.
A patient with treatment refractory schizophrenia is admitted to the mental health unit for clozapine induction. At team rounds the psychiatrist and medical team go over indications and common things to look for with clozapine.
1: What are the indications?
Answer: Schizophrenia not responding to typical or other atypical antipsychotics. Clozapine is a very potent medication and is a carefully considered treatment decision with a variety of side effects some of which are potentially dangerous
2: What is the MOA?
Clozapine has effects at the serotonergic, dopaminergic, histamine, muscarinic, and other receptors. It is liver metabolized and renally excreted. Significant first pass effect and metabolism.
3: What are the common side effects ?
GI side effects are common - drooling, hypersalivation. As with other atypical antipsychotics (olanzapine) weight gain and impaired glucose metabolism can occur
4: What are the dangerous side effects ?
Numerous black box warnings.
- Bone marrow suppressive - CBC prior to and during induction course. Monitor granulocytes, neutrophils, and blood counts
- Cardiac toxicity - Myocoarditis (can occur within a few weeks of induction or later - troponin and CRP monitoring can be done for myocarditis. If abnormal proceed to Echo and cardiology consult ) QT prolongation is NOT common
- Can lower the seizure threshold. More commonly seen with higher doses
- orthostatic hypotension and syncope can occur
Clozapine has restricted access in some areas. This is a drug prescribed usually only by psychiatrists. It is a commonly tested drug and remember to be aware of side effects other than just bone marrow related issues. That’s been tested for years and the next likely side effects to be tested on include cardiac side effects and lowering of the seizure threshold.
That’s all for tonight guys I’ll try to come back another time.
Good luck with your studying