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Valproate as prophylaxis for clozapine-induced seizures: survey of practice

  • Anna Sparshatt, Eromona Whiskey and David Taylor (a1)
Abstract
Aims and Method

To evaluate the prescribing of valproate in clozapine-treated individuals who may be at risk of seizure. We collected point-prevalent clinical characteristics and demographics of all in-patients prescribed clozapine in an acute mental health trust. Data were collected from case notes, electronic records and drug charts, and analysed against a set audit standard.

Results

Data were collected for 81 in-patients. Of all deemed to be at risk of seizure (n=37) only 24% were prescribed valproate at a therapeutic plasma level.

Clinical Implications

The majority of patients prescribed clozapine at risk of seizures were not adequately protected from this risk. Clear guidelines are required.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Valproate as prophylaxis for clozapine-induced seizures: survey of practice

  • Anna Sparshatt, Eromona Whiskey and David Taylor (a1)
Submit a response

eLetters

Community Patients prescribed Clozapine: high number rated 'at risk'

Joan Rutherford
16 October 2008

We read with interest the survey by Sparshatt et al on the use of Valproate as prophylaxis for Clozapine induced seizures. It spurred us on to do a similar survey within Kingston Community Mental Health Team, and we were surprised at how many of our patients were rated as high risk.

Within our team there are a total of 244 patients of which 94 (39%) are diagnosed with schizophrenia or schizo- affective disorder. Of the 94, 41 (44%) are considered treatment resistant, and 15 are prescribed Clozapine. At the time of our survey none of the 15 were inpatients. Using the same criieria as Sparshatt et al ie Clozapine level 0.6 mg/l ormore, or dose at/more than 600 mg /day or co-prescribed additional epileptogenic medication and/or with an existing seizure disorder, we found five patients, ie 40% of our sample, were high risk and this was dueto having a Clozapine level over 0.6 in all five cases. Two of these patients had had seizures since commencing Clozapine and both were prescribed Valproate. Another two were also prescribed epileptogenic medication.

Our survey raised three issues for us:

Firstly,the Maudsley Guidelines suggest prescribing Valproate if Clozapine serum level is at or greater than 0.5mg/l, so we wondered why the level of 0.6 mg/l was selected the high risk level.

Secondly, we did not see any reference to the smoking status of the patients in the survey, although the Maudsley Guidelines do comment about lower Clozapine serum levels in smokers. One of our 15 patients reported markedly increased sedation after he stopped smoking. Although his Clozapine serum levels increased by 100%, at no time was this over 0.6 mg/l, but we wondered whether smoking cessation in patients on Clozapine could or should trigger them into the high risk group.

Thirdly, we wondered whether the Maudsley Guidelines could offer further advice to clinical teams on Clozapine serum levels? We would appreciate advice when our patients take Clozapine at split doses, morningand evening, as we are not clear the impact this has on the serum Clozapine level; also as to whether the Guidelines could advise on good practice with regard to the intervals between Clozapine serum level sampling.

Yours sincerely

Drs Joan Rutherford, Sara Beleil and Nanaji Pala

Refs:SPARSHATT, A., WHISKEY, E. and TAYLOR, D. (2008) Valproate as prophylaxisfor clozapine-induced seizures: survey of practice. Psychiatric Bulletin, 32, 262-265.

TAYLOR, D., PATON, C. and KERWIN, R (2007) The Maudsley Prescbing Guidelines 9th Edition. Informa Healthcare.
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Conflict of interest: None Declared

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