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Clozapine and Treatment-Refractory Illness
Published in Ragy R. Girgis, Gary Brucato, Jeffrey A. Lieberman, Understanding and Caring for People with Schizophrenia, 2020
Ragy R. Girgis, Gary Brucato, Jeffrey A. Lieberman
Despite all these potential side effects, which range from mild and common to rare and life-threatening, clozapine remains definitively superior to other antipsychotic medications for treatment-refractory conditions. Because of all these potential side effects, however, clozapine is also sorely underutilized. Many patients and families are discouraged by the potential side effects, if not downright frightened of them, or else simply do not want the burden of having their blood drawn every week. Many providers have limited experience with clozapine and/or are too worried about litigation arising from a patient developing a severe side effect. Therefore, while clozapine is every bit a potential miracle drug for many people with schizophrenia, it is also emblematic of the challenges faced every day by patients, families, and providers.
Paper 2: Answers
Published in Sabina Burza, Beata Mougey, Srinivas Perecherla, Nakul Talwar, Practice Examination Papers for the MRCPsych Part 1, 2018
Sabina Burza, Beata Mougey, Srinivas Perecherla, Nakul Talwar
B, G. Neither is recommended as first-line treatment for schizophrenia or other psychotic states. Clozapine is licensed for schizophrenia in patients who are unresponsive to or intolerant of conventional antipsychotics. Thioridazine may only be prescribed under specialist supervision as a second-line treatment for schizophrenia. (9)
Paper 3 Answers
Published in Hayley Dawson, Anna Trigell, EMQs for the nMRCGP® Applied Knowledge Test, 2018
Depot risperidone is fairly new and supposedly set to revolution-ise the management of chronic schizophrenia. The early diagnosis in psychosis teams are becoming ubiquitous, and are keen to get their hands on people to reduce chronic morbidity. You would be very unlikely to have much to do with the prescribing of a drug such as clozapine, but it is worth knowing the indication and the potential harm that it may cause in case you are asked to be involved in the prescribing of this drug.
Update on novel antipsychotics and pharmacological strategies for treatment-resistant schizophrenia
Published in Expert Opinion on Pharmacotherapy, 2022
Andrea de Bartolomeis, Mariateresa Ciccarelli, Licia Vellucci, Michele Fornaro, Felice Iasevoli, Annarita Barone
According to the guidelines, clozapine should be offered after the failure of at least two adequate antipsychotic trials, including at least one with a long-acting injectable drug [5,37]. On the other hand, the probability of non-response to the first antipsychotic administered has been found to be similar to that with a second different antipsychotic. Thus, it is possible to hypothesize a treatment-resistance condition on the basis of a single course of antipsychotic treatment [38]. In this regard, the results of the OPTiMiSE study supported the strategy of switching clozapine also in patients with first-episode schizophrenia who do not respond to their initial antipsychotic treatment [39]. With respect to secondary acquired forms of resistance, the prevention of multiple relapses of the disease as well as of tardive dyskinesia and supersensitivity psychosis should be emphasized [15,37,40]. For instance, measures to be observed include ensuring proper adherence, avoiding abrupt discontinuation, under-dosing or too short duration of therapy, early detection of extrapyramidal symptoms (EPS) or elevation in prolactin levels, prescribing the lowest effective dose of antipsychotic during maintenance, preventing substance abuse [40].
New approaches to antipsychotic medication adherence – safety, tolerability and acceptability
Published in Expert Opinion on Drug Safety, 2022
Sharon Taub, Amir Krivoy, Eromona Whiskey, Sukhi S. Shergill
Traditionally, clozapine is available for oral administration only and has no long-acting pharmaceutic formulation. Hence, there are practical difficulties to prescribe oral clozapine for severe schizophrenia patients in their acute, agitated, psychotic state, who are often less cooperative with oral treatment. Yet, this subgroup of patients is the most likely to benefit from clozapine in the long term. A retrospective clinical study recently published [46] assessed effectiveness of short-acting intramuscular (IM) clozapine treatment. Thirty-nine initially nonadherent patients treated with clozapine injections were compared with a cohort of 162 patients treated with oral clozapine exclusively. All participants were inpatients diagnosed with treatment-refractory psychosis. Almost all (92%) of the IM clozapine patients later agreed to switch to oral formulation, and 76% of them remained on clozapine after 2-year follow-up period. Clozapine discontinuation rates were similar in both groups. The authors conclude that IM clozapine can be effectively used as a temporary bridge for long-term oral clozapine administration.
Attitude towards and experience with clozapine of patients and their caregivers after three months of starting of clozapine
Published in Nordic Journal of Psychiatry, 2021
Meha Verma, Sandeep Grover, Subho Chakrabarti, Devakshi Dua
Clozapine is an atypical antipsychotic medication found to be more efficacious than other antipsychotics. However, due to its side effect profile, its use is usually limited to patients with treatment-resistant schizophrenia (TRS) [1]. It is possibly the only antipsychotic medication that has been shown to be superior to other medications in patients with schizophrenia having partial or non-response and is the only evidence-based medication for TRS [2]. The CATIE trial suggested that the time to discontinuation for clozapine is longer than other atypical antipsychotics, and it is more effective than quetiapine in the management of depressive symptoms in patients with chronic schizophrenia [3,4]. Data from other studies also suggest that a significant proportion of patients started on clozapine continue the same in the long run [5]. Clozapine has also been shown to reduce the incidence of suicide [6], aggression [7], risk of relapse of substance abuse [8], rate of rehospitalization [9] and is associated with the lowest risk of premature mortality even after controlling for clinical monitoring and other potential confounders [10,11].