What Lab Test to Review Before Giving Pateitn Clonazepine

This content was published in 2014. We do not recommend that you have whatsoever clinical decisions based on this data without first ensuring you have checked the latest guidance.

Objectives

Studying this article will help y'all to:

• Understand the frequency of blood monitoring for patients taking clozapine
  
• Empathize restrictions on how much clozapine can be dispensed
• Ensure seamless transfer of care between NHS organisations for people taking clozapine

Clozapine is an singular antipsychotic that is used for handling-resistant schizophrenia. The drug is discipline to strict monitoring requirements because information technology is associated with serious side effects, such as neutropenia, agranulocytosis, seizures, myocarditis and cardiomyopathy. The incidence of neutropenia amid clozapine-treated patients is ii% and agranulocytosis 0.8%.

Some 30–60% of patients with handling-resistant schizophrenia will respond to clozapine.1,2The decision to prescribe clozapine is usually made for patients who accept been treated unsuccessfully with at to the lowest degree two other antipsychotic medicines (i of which is another atypical antipsychotic). A contempo Cochrane review showed that clozapine had a number needed to treat of 21 versus typical antipsychotics for preventing relapse.^three About 80% of patients with schizophrenia will relapse without antipsychotic treatment.

What action to take

Pharmacists who run across a prescriptionfor clozapine should plant:

• What brand of clozapine the patient is taking
  
• The frequency of full blood count (FBC) tests and when the concluding one was taken
• The current dose of clozapine
• The patient'southward adherence to clozapine treatment — specifically, whether he or she has missed a dose more than 48 hours beforehand
• Who currently supplies the patient's clozapine

If the patient has been admitted to hospital, you should constitute whether he or she has brought whatever clozapine with them.

Brand of clozapine

Each clozapine manufacturer has its own mandatory monitoring organisation. The prescribing consultant, patient and supplying chemist's shop each have to be registered with the clozapine manufacturer. There are 3 brands of clozapine currently bachelor in the United kingdom, namely:

• Clozaril (Novartis) — monitoring website world wide web.clozaril.co.uk
• Denzapine (Genus) — monitoring website www.denzapine.co.u.k.
• Zaponex (Teva United kingdom of great britain and northern ireland) — monitoring website www.ztas.co.great britain
  

The different brands are bioequivalent. The blood results demand to be communicated to the relevant monitoring service to ensure you lot tin safely dispense further supplies of clozapine.

Timing of claret tests

Patients' take chances of agranulocytosis reduces the longer they take the medicine (meet Box 1) and the monitoring requirements reflect this. Patients newly started on clozapine must have an FBC taken weekly for the first18 weeks of treatment and then fortnightly for the next 34 weeks. Afterward that they receive monthly monitoring for every bit long equally they are taking clozapine.The amount of clozapine that can be supplied varies depending on a patient'southward phase of monitoring. Specifically:

• Weekly FBC tests — maximum of 10 days' supply of clozapine (from the appointment of the near recent blood test)
  
• Fortnightly FBC tests — maximum of 21 days' supply of clozapine (from the date of the most recent blood test)
  
• Monthly FBC tests — maximum of 42 days' supply of clozapine (from the appointment of the most recent claret test)

The clozapine manufacturers use a traffic light system (dark-green, amber, crimson) for guiding dispensing on the footing of FBC results, as described in Box 2.

Side effect monitoring

Every patient receives an electrocardiogram earlier they are initiated on clozapine.Although there is no routine monitoring for myocarditis or cardiomyopathy during treatment, patients showing signs of heart failure should have their therapy stopped until the condition is investigated. Because the presentation of cardiomyopathy varies, investigations should be carried out for patients taking clozapine who develop palpitations, sweating and breathing difficulties.^four

Adherence to clozapine

Patients who have missed clozapine doses for more than 48 hours will demand to have the medicine retitrated. They cannot continue taking their usual maintenance dose. If they miss more than three days of clozapine their blood testing frequency may need to alter. The relevant clozapine manufacturer or mental health pharmacy should be contacted for further advice.

Continuity of care

In the vast majority of cases clozapine will exist prescribed by a consultant psychiatrist and dispensed by a infirmary chemist's. A customs pharmacy may be supplying clozapine nether a service level understanding for patients receiving monthly blood tests. Contact the supplying chemist's to find out the patient's current dose of clozapine, when he or she terminal collected supplies, the brand of clozapine and the directions prescribed. Clozapine often does not appear on GP records when a listing of current medicines is obtained from a surgery. Ask patients whether they are receiving whatsoever other medicines apart from through the GP, especially if they have a diagnosis of schizophrenia and do non appear to exist prescribed an antipsychotic.

For patients who have been admitted to hospital, it is important to contact the pharmacy that supplies their clozapine.This ensures the pharmacy squad is enlightened of the admission, can advise on dosing and blood tests and can pass on the information to the mental wellness squad. This also provides an opportunity to discuss ongoing supplies of clozapine for the patient during their inpatient stay and at the time of discharge.

During admission, contact the relevant clozapine monitoring service with relevantFBC results as required and confirm theFBC is acceptable before dispensing more clozapine. You lot will need the patient's name and date of nascence to practice this.

Check that none of the new medicines prescribed interacts with clozapine (eg, erythromycin and ciprofloxacin can increase clozapine levels, rifampicin tin profoundly reduce clozapine levels). Patients who end smoking while an inpatient volition demand to have their doses reduced because smoking induces clozapine metabolism.

On belch, contact the patient'southward clozapine chemist's for directions on how much clozapine to dispense. Arrangements can also be made for the patient to be booked into the advisable clozapine dispensary for their side by side FBC and for further clozapine supplies.

Specialist input

Specialist mental health pharmacists can advise on clozapine monitoring and dose titration in certain clinical scenarios, for example, patients who are:

• Physically unwell
  
• Receiving surgery
  
• Undergoing intensive intendance
  
• Zilch-by-oral fissure

Some hospitals take a liaison psychiatry team that can suggest and monitor mental health patients and their psychiatric conditions during acute admissions.It is crucial that all staff involved with the prescribing, dispensing and administration of this medicine are trained appropriately.They demand to know what processes to follow and when to seek specialist help —getting information technology wrong can be catastrophic.

Discussion

• How do you bargain with medicines that require strict monitoring only which you see rarely in your practise?
  
• How practise you deport out the medicines reconciliation process for specialist medicines?
• What is your team'southward approach to recording decisions about clozapine monitoring and dispensing?

References

ane National Found for Wellness and Care Excellence. Core interventions in the management of schizophrenia in principal and secondary care. March 2009. world wide web.nice.org.uk/cg82 (accessed twenty May 2014).

ii Barnes T and the Schizophrenia Consensus Grouping of the British Association for Psychopharmacology. Testify-based guidelines for the pharmacological treatment of schizophrenia: recommendations from theBritish Association for Psychopharmacology. Journal o fPsychopharmacology 2011;25:567–620.

iii Essali A, Al-Haj Haasan N, Li C, et al. Clozapine versus typical neuroleptic medication for schizophrenia(review). Cochrane Database of Systematic Reviews 2009, Upshot one.

4 Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry. 11th edition. London: Wiley Blackwell; 2012.

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Source: https://pharmaceutical-journal.com/article/ld/how-clozapine-patients-can-be-monitored-safely-and-effectively

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