Skip to main content

Clozapine rapid retitration in the community: an assertive approach can prevent admissions

  • Nikola Nikolić (a1), Kevin Kilbride (a2) and Patrick Preston (a3)

Rapid retitration of clozapine may be necessary to reduce the known high risk of mental state destabilisation in patients who have had a 48 h treatment break. It may carry a high risk of complications, including seizures and myocarditis. We reflect on the literature on standard and rapid retitration and present a case of rapid retitration in the community. In this case, of a 54-year-old homeless man with treatment-resistant schizophrenia and polysubstance misuse, we safely retitrated clozapine in a community setting four times during a 6-month period; each retitration was completed over 4 days. We used a specific protocol based on his psychiatric history. We are now more confident in delivering clozapine retitration to other patients, thus preventing unnecessary admissions.


N. N. has received honoraria from Janssen Pharmaceuticals.

Corresponding author
Correspondence Nikola Nikolić, HSE Dublin North East, c/o St Mary's Hospital, Acres Road, Dublin 20, Ireland. Email:
Hide All
Cohen, D, Bogers, JPAM, van Dijk, D, et al. (2012) Beyond white blood cell monitoring: screening in the initial phase of clozapine therapy. Journal of Clinical Psychiatry, 73: 1307–12.
Grenade, LL, Graham, D, Trontell, A (2001) Myocarditis and cardiomyopathy associated with clozapine use in the United States. New England Journal of Medicine, 345: 224–5.
Ifteni, P, Nielsen, J, Burtea, V, et al. (2014a) Effectiveness and safety of rapid clozapine titration in schizophrenia. Acta Psychiatrica Scandinavica, 130: 25–9.
Ifteni, P, Correll, CU, Nielsen, J, et al. (2014b) Rapid clozapine titration in treatment-refractory bipolar disorder. Journal of Affective Disorders, 166: 168–72.
Kelly, DL, McMahon, RP, Liu, F, et al. (2010) Cardiovascular disease mortality in chronic schizophrenia patients treated with clozapine: a retrospective cohort study. Journal of Clinical Psychiatry, 71: 304–11.
Kiviniemi, M, Suvisaari, J, Koivumaa-Honkanen, H, et al. (2013) Antipsychotics and mortality in first-onset schizophrenia: prospective Finnish register study with 5-year follow-up. Schizophrenia Research, 150: 274–80.
Leon, J, Tang, Y-L, Baptista, T, et al. (2015) Titrating clozapine amidst recommendations proposing high myocarditis risk and rapid titrations. Acta Psychiatrica Scandinavica, 132: 242–3. (2016) Clozaril 100mg Tablets – Summary of Product Characteristics (SPC). Irish Pharmaceutical Healthcare Association ( Accessed 22 May 2018.
Nielsen, J, Damkier, P, Lublin, H, et al. (2011) Optimizing clozapine treatment. Acta Psychiatrica Scandinavica, 123: 411–22.
Poyraz, CA, Özdemir, A, Sağlam, NGU, et al. (2016) Rapid clozapine titration in patients with treatment refractory schizophrenia. Psychiatric Quarterly, 87: 315–22.
Ronaldson, KJ, Fitzgerald, PB, Taylor, AJ, et al. (2011) A new monitoring protocol for clozapine-induced myocarditis based on an analysis of 75 cases and 94 controls. Australian and New Zealand Journal of Psychiatry, 45: 458–65.
Ronaldson, KJ, Fitzgerald, PB, Taylor, AJ, et al. (2012) Rapid clozapine dose titration and concomitant sodium valproate increase the risk of myocarditis with clozapine: a case–control study. Schizophrenia Research, 41: 173–8.
Ronaldson, KJ, Fitzgerald, PB, McNeil, JJ (2015) Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatrica Scandinavica, 132: 231–40.
Taylor, DM, Barnes, TRE, Young, AH (2018) The Maudsley Prescribing Guidelines in Psychiatry (13th edn). John Wiley & Sons.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Advances
  • ISSN: 2056-4678
  • EISSN: 2056-4686
  • URL: /core/journals/bjpsych-advances
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Clozapine rapid retitration in the community: an assertive approach can prevent admissions

  • Nikola Nikolić (a1), Kevin Kilbride (a2) and Patrick Preston (a3)
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *