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6.1.1 – Psychosis – Palliation – Clozapine

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This is dr. nicholas hatcher and  psychopharmacologic and psychotherapeutic  here is a reminder of where we are in the  series now that we’ve considered the various   this lecture will emphasize a specialized topic  regarding the psychopharmacologic principles of   psychosis treatment clozapine treatment resistance  schizophrenia

Affects 20 to 30 percent of all   patients diagnosed with schizophrenia clozapine  is a potential option for that patient population   clozapine was initially shown to be more effective  than chlorpromazine the proteotypical first   generation antipsychotic it then showed advantage  over several first generation antipsychotics

In   various trials the cutlass ii study found that  patients failing to respond to two or more   antipsychotics responded well to clozapine the  catie trial revealed effectiveness over quetiapine   has been shown to reduce mortality over other   antipsychotic agents including first generation  antipsychotics risperidone

And quetiapine   antipsychotic with several considerations   the most important of which is that you must check  a baseline complete blood count or cbc in order to   ensure that white blood cells are greater than 3.5  and the absolute neutrophil count is greater than   this must be monitored on a frequent basis  

A baseline ekg is also required to ensure that the  qtc is less than 500 milliseconds otherwise it is   best to re-evaluate after the removal of other qtc  prolonging medications clozapine is a medication   that must be titrated slowly it takes several  weeks to get to the optimum dose it is important   to know also that if a

Patient stops clozapine for  greater than 48 hours it must be re-titrated in   consecutive slides i provided you with additional  information on monitoring clozapine here i’ve   listed monitoring considerations for clozapine  one in 30 or 3.8 percent of patients develop mild  neutropenia one in 100 or 0.9 percent of patients  

Develop severe neutropenia in order to monitor  for this it’s generally recommended to do a cbc   every week for six weeks every two weeks then  for six months then monthly for six months   absolute neutrophil count drops below  patients on clozapine are three times more likely  to develop myocarditis than neutropenia the  

Classical presentation is a patient on clozapine  presents with chest pain dyspnea flu-like symptoms   with troponinemia and an increase in c-reactive  protein when this is the case stop clozapine   will be discussed in the following slide   and send the patient to the hospital for an ekg  eosinophilia may be noted on the cbc it

May  indicate any of the following myocarditis   when it’s combined with an elevated troponin or  c-reactive protein nephritis when it’s combined   serum creatinine pancreatitis when it’s   combined with an elevated lipase or hepatitis  when there is combined derangement of lfts it’s   important here to stop clozapine

If there’s any  significant finding and treat the underlying issue   sialorrhea is a common issue that  here it’s important to monitor for breath sounds  cough dyspnea any presence of fever respiratory   i’ve listed here three common management  constipation can be a significant issue for  patients on clozapine in fact they

Can develop   a fatal alias while on clozapine it’s important  to monitor bowel sounds bowel patterns and the   presence of nausea or vomiting to help with this  try to decrease any systemic anticholinergic   activity look at their other medications to see  if they’re on any other anticholinergic drugs   to prevent

This it may help to prophylactically  treat the patient with docusate and biscodyl   or peg maintain a high fiber diet and increase  fluid intake if this is ineffective i have listed   some medications here that have shown some benefit  in helping abrupt discontinuation of clozapine   may result in cholinergic rebounds this

Causes the  symptoms of delirium nightmares and diarrhea it is   recommended to give benztropine one milligram for  every 50 milligrams of clozapine in the non-smoker   smoker as i mentioned before if clozapine   clozapine seizures is another consideration   orthostatic hypotension is much more common   so ask the

Question did they just syncopize due to  orthostatic hypotension or was it truly a seizure   if concerned depakote is a better option than  lamictal because it covers both generalized and   better than phenytoin and carbamazepine   here i’ve listed a graph showing clozapine  levels there are three key reasons to check  

Clozapine levels number one if there’s a poor  response at 600 milligrams number two if there’s   for downloadable content such as written  notes powerpoint slides and more related   you can also support my goal of continuing  to provide new content through patreon where   becoming a patron will provide you with access 

To downloadable content as i create new content   thank you for your support here are my references  for this presentation thank you for watching.

Transcribed from video
6.1.1 – Psychosis – Palliation – Clozapine By Nicholas Hatcher