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Strategies for Successful Use of Clozapine: A Prac ...
Presentation Q&A
Presentation Q&A
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Video Transcription
Let me talk to you, Yvonne, about some of the questions that have been coming in. Great. So there are two on troponins. How often, if at all, do you order troponins after the first eight weeks of treatment? That's a great question. We're not currently recommending it afterwards. The risk for myocarditis is the highest within the first three to four months, and I would say have a low threshold for ordering it if your patient's having any kind of constitutional symptoms, whether it's fatigue greater than one might expect from clozapine or vague chest pain or even flu-like symptoms. And here's another question on that. Do you need to check troponins when uptritrating the dose of clozapine or only during initiation? That's a great question. I don't think there's a lot of data on that. I think one could logically extrapolate that the risk for myocarditis would be greater in an uptitration that occurred later in treatment, but I think it depends a little bit on the uptitration. If you're really just increasing from 300 to 350 to 400 milligrams, I'm not sure I'd be worried in that case, but if you were making a really dramatic jump from 300 to 600, then maybe it'd be worth considering. What about Botox for sialorrhea? For sialorrhea? Yeah. Wow, that's a great question. I don't know the literature off the top of my head. I'll have to look into it. Yeah, I'm sorry. I don't know. I don't know what to say about that. That's okay. That's okay. The person can enter a consult and we can answer them. Why not Miralax instead of a GI stimulant for constipation? That would be fine. Miralax is very commonly used and that's fine. Yeah. Okay, great. Transitioning from an LAI, how long after injection will you start clozapine titration? What a great question. I love this. If one is transitioning from an LAI to a standard PO, the guidelines are to start the PO full dose at the time the next LAI would be scheduled, that the patient would be scheduled to receive the next LAI. We can't do that with clozapine. I would think that would mean probably starting the titration, like for instance, if it were a Q4 week LAI, starting the titration two weeks after the last injection and getting the patient up to maybe 200 milligrams by the time they would be due for their next LAI would be appropriate. It's possible if they started having breakthrough symptoms before they reached that dose of clozapine or maybe they need a target dose of 300 or 350 or 400 milligrams of clozapine. It's possible they could need some PO supplementation of the same agent that the LAI was, and that would mean a very, very, very brief window of polypharmacy with clozapine, but generally I would say monotherapy with clozapine starting two weeks before their next LAI is due. Okay, is there any recommendation for re-challenging people with a history of inflammatory bowel disease with history of bowel obstruction while on clozapine? Again, I don't know that specific literature, unfortunately, and all I can say in all of these cases of re-challenge is that it tends to be a very individual case-by-case basis sort of determination. All right, how long after clozapine has been discontinued for neurotropenia, do you monitor A and C after A and C has returned to normal? Actually, there's no guidelines for, if your patient's not on clozapine anymore, there's no guidelines for continuing to monitor afterwards. That I know of. I hope I'm not misspeaking. I'm sure SMI advisor consultant could correct me. Right. My patient is stabilized under clozapine 250 milligrams a day, but have a clozapine level of 750 milligrams, NG per milligram, verified twice. There's no side effects clinically. Should I decrease those? No, definitely not. As I mentioned in my slide on serum drug monitoring or serum level monitoring, we have to treat the patient, their symptoms, and their side effects, and not the serum level. And 750 is not even very concerning. As I mentioned, the serum levels tend not to correlate well with the dose of medication from one individual to another. As long as there are no side effects, I just wouldn't be worried at all. Great. Any recommendation for aggression or agitation in a forensic patient who were titrating on clozapine? As I suspect the person asking the question knows, clozapine has a special indication for aggression in patients with schizophrenia, but it might just take some time to have its effects. I'm not sure if they're asking if there should be another adjunctive agent for aggression on top of that, but the good news is that clozapine is known to be especially effective both for suicidality and aggression. All right. Any combination antipsychotic you recommend for a non-responder to clozapine? So what would you do next? Yeah. That's a great question. There's evidence. There's pretty strong evidence for only one additional agent to add on to clozapine, which is aripiprazole. The specific paper that I'm thinking of most recently is a JAMA Psych 2019 paper. The lead author is Tihonen, Jarl Tihonen, and they did a study of 63,000 patients in, I believe, Finland with schizophrenia, and they looked at polypharmacy in those patients and rates of rehospitalization. The only combination that was superior to clozapine monotherapy was clozapine plus aripiprazole. Wonderful. Well, I would say that this webinar was excellent, and thank you for answering all of these specific questions.
Video Summary
In this video, Yvonne answers several questions related to troponin testing, Botox for sialorrhea, Miralax for constipation, clozapine titration after transitioning from a long-acting injectable (LAI), re-challenging individuals with a history of inflammatory bowel disease, monitoring A and C after discontinuing clozapine for neutropenia, managing high clozapine levels without side effects, managing aggression or agitation in forensic patients on clozapine, and combination antipsychotics for non-responders to clozapine. Yvonne recommends troponin testing in the first three to four months of treatment if patients experience constitutional symptoms. She is unsure about the use of Botox for sialorrhea and suggests further research. Miralax is a suitable option for constipation. The timing of clozapine titration after transitioning from an LAI depends on the LAI dosing schedule. Re-challenging individuals with a history of inflammatory bowel disease on clozapine should be done on a case-by-case basis. After clozapine discontinuation for neutropenia, there are no guidelines for continued monitoring. Yvonne suggests treating the patient based on symptoms and side effects rather than serum levels. Aggression or agitation in forensic patients on clozapine may improve with time, but additional adjunctive agents can be considered. The only combination antipsychotic recommended for non-responders to clozapine is clozapine plus aripiprazole, according to a study published in JAMA Psychiatry in 2019. Overall, Yvonne provides helpful insights and recommendations, while acknowledging the need for individualized care. No credits were provided in the video transcript.
Keywords
troponin testing
Botox for sialorrhea
Miralax for constipation
clozapine titration
combination antipsychotics
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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