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Questions and Answers
An adequate trial of augmentation with clozapine may take up to 12 weeks.
An adequate trial of augmentation with clozapine may take up to 12 weeks.
False
It is advisable to choose a medication that increases the common side effects of clozapine.
It is advisable to choose a medication that increases the common side effects of clozapine.
False
Some studies suggest that a 6-week trial may be enough for augmentation with clozapine.
Some studies suggest that a 6-week trial may be enough for augmentation with clozapine.
True
The suggested duration for an adequate trial of augmentation with clozapine is 5 weeks.
The suggested duration for an adequate trial of augmentation with clozapine is 5 weeks.
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Choosing an appropriate augmentation medication is crucial to avoid worsening side effects when using clozapine.
Choosing an appropriate augmentation medication is crucial to avoid worsening side effects when using clozapine.
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Clozapine should be offered after the failure of four antipsychotics according to the NICE guidelines.
Clozapine should be offered after the failure of four antipsychotics according to the NICE guidelines.
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The treatment of newly diagnosed schizophrenia may include psychological interventions such as CBT.
The treatment of newly diagnosed schizophrenia may include psychological interventions such as CBT.
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Before starting antipsychotic medication, only weight should be recorded as a baseline investigation.
Before starting antipsychotic medication, only weight should be recorded as a baseline investigation.
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Dosages outside the range given in the BNF or SPC require justification and recording of reasons.
Dosages outside the range given in the BNF or SPC require justification and recording of reasons.
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Patients should be monitored for weight and waist circumference on a monthly basis during the first year of treatment.
Patients should be monitored for weight and waist circumference on a monthly basis during the first year of treatment.
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A personal history of cardiovascular disease warrants an electrocardiogram (ECG) before starting antipsychotic medication.
A personal history of cardiovascular disease warrants an electrocardiogram (ECG) before starting antipsychotic medication.
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The service user's personal preferences should not influence the choice of antipsychotic medication.
The service user's personal preferences should not influence the choice of antipsychotic medication.
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Antipsychotic medication loading doses are routinely recommended for all medications prescribed for schizophrenia.
Antipsychotic medication loading doses are routinely recommended for all medications prescribed for schizophrenia.
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Patients should be advised about using sunscreen to prevent skin photosensitivity when taking chlorpromazine.
Patients should be advised about using sunscreen to prevent skin photosensitivity when taking chlorpromazine.
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Antipsychotic medication should be given at a high dose from the start according to the NICE guidelines.
Antipsychotic medication should be given at a high dose from the start according to the NICE guidelines.
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Cardiovascular side effects are one of the considerations in drug choice for schizophrenia treatment.
Cardiovascular side effects are one of the considerations in drug choice for schizophrenia treatment.
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Regular combined antipsychotic medication can be initiated for any patient at any time.
Regular combined antipsychotic medication can be initiated for any patient at any time.
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Monitoring nutritional status and physical activity is not necessary before starting antipsychotic medication.
Monitoring nutritional status and physical activity is not necessary before starting antipsychotic medication.
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Clozapine should be offered to patients after two different antipsychotic treatments, regardless of their substance use history.
Clozapine should be offered to patients after two different antipsychotic treatments, regardless of their substance use history.
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The responsibility for physical monitoring during the treatment period lies solely with the patient's primary care physician.
The responsibility for physical monitoring during the treatment period lies solely with the patient's primary care physician.
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Patients should only be assessed for fasting blood glucose at the beginning of their treatment.
Patients should only be assessed for fasting blood glucose at the beginning of their treatment.
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Study Notes
Clozapine Treatment
- Clozapine treatment should be considered after at least two other antipsychotic drugs have failed
- Clozapine should be offered to patients whose illness has not responded adequately to treatment despite sequential use of at least two different antipsychotic drugs alongside psychological therapies.
- Clozapine should be offered only if substance misuse has been ruled out
- At least one of the other antipsychotic drugs should be a non-clozapine second-generation antipsychotic
- An adequate trial of clozapine augmentation may need to be 8–10 weeks (some data suggest 6 weeks may be enough)
- Choose an augmentation drug that does not compound the common side effects of clozapine
Dosage Adjustment
- Justify and record reasons for dosages outside the range given in the BNF or SPC
- Record rationale for continuing, changing, or stopping medication and effects of such changes
- Trial medication at optimum dosage for 4–6 weeks (at least half of this period is sufficient if no effect is seen)
Regular Monitoring During Treatment (especially during titration)
- Efficacy: Changes in symptoms and behavior
- Side Effects: Consider overlap between certain side effects and clinical features of schizophrenia (e.g., akathisia, agitation, anxiety)
- Adherence
- Weight: Weekly for the first 6 weeks, then at 12 weeks, 1 year, and annually
- Waist Circumference: Annually
- Pulse and Blood Pressure: At 12 weeks, 1 year, and annually
- Fasting Blood Glucose, HbA₁c, and Blood Lipids: At 12 weeks, 1 year, and annually
- Nutritional Status, Diet, and Physical Activity
- Physical Monitoring: Responsibility of the secondary care team for one year or until the patient is stable.
Substance Use Discussion
- Discuss the use of:
- Alcohol, Tobacco, Prescription, and Non-Prescription Medication, including illicit drugs and their potential interactions with prescribed therapies.
Antipsychotic Medication Guidelines
- Loading Dose: Do not use a loading dose of antipsychotic medication, unless it is a depot form (applicable for olanzapine and paliperidone)
- Combination Medications: Do not routinely initiate regular combined antipsychotic medication, except for short periods when changing medication
- Chlorpromazine: Warn patients about its potential to cause skin photosensitivity, advise using sunscreen if necessary
-
Depot/Long-Acting Injectable Antipsychotic: Consider offering this to individuals who:
- Prefer such treatment after an acute episode
- Are non-adherent to oral treatment or prefer this method
NICE Guidelines for the Treatment of Schizophrenia
- The 2009 NICE Guidelines differed significantly from previous guidelines
- They recommend that clozapine be "offered" after the failure of two antipsychotics
- They emphasize patient involvement in decisions
- New NICE Guidelines appeared in February 2014 and were reviewed in March 2019.
NICE Guidelines - Summary
- For people with newly diagnosed schizophrenia, offer:
- Oral antipsychotic medication
- Psychological interventions (CBT or family intervention)
- Provide information and discuss the benefits and side-effect profile of each drug with the service user
- The choice of drug should be made collaboratively by the service user and healthcare professional, considering:
- The relative potential of individual antipsychotic drugs to cause:
- Extrapyramidal side effects (including akathisia)
- Cardiovascular side effects (including weight gain)
- Metabolic side effects
- Hormonal side effects (including raised prolactin levels)
- Other side effects (including unpleasant subjective experiences)
- The views of the carer where the service user agrees
- The relative potential of individual antipsychotic drugs to cause:
Before Starting Antipsychotic Medication
- Undertake and record the following baseline investigations:
- Weight
- Waist circumference
- Pulse and blood pressure
- Fasting blood glucose, HbA1c, blood lipid profile, prolactin
- Assessment of movement disorders
- Assessment of nutritional status, diet, and level of physical activity
Before Starting Medication
- Offer the person with schizophrenia an electrocardiogram (ECG) if:
- Specified in the SPC
- A physical examination has identified cardiovascular risk (such as a diagnosis of high blood pressure)
- There is a personal history of cardiovascular disease
- The service user is being admitted as an inpatient
Treatment Considerations
- Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial, keeping in mind:
- Recording of indications and expected benefits and risks
- The expected timeframe for a change in symptoms and appearance of side effects
At the Start of Treatment
- Give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range provided in the British National Formulary (BNF) or SPC
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Description
This quiz covers the protocols for clozapine treatment, including indications for use, dosage adjustments, and considerations for patient history. Review key factors in determining when to initiate clozapine therapy, especially after other antipsychotics have failed. Understanding the guidelines for dosage documentation and adjustments is also essential.
