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Clozapine antipsychotic polypharmacy: audit of use and patient monitoring

  • Sam Wilson (a1), Ross Hamilton (a1), John Callender (a1), Angela MacManus (a1), Sheila Howitt (a2) and Blessing Okpo (a3)...
Abstract
Aims and method

We audited prescribing within our area to ascertain how widespread the practice of antipsychotic polypharmacy using clozapine was, and whether it was being carried out within existing standards, including those of high-dose monitoring when required.

Results

Data on 169 patients were reviewed in year one, rising to 193 in year three. Around 30% of patients on clozapine received additional antipsychotic medication. A disturbingly low proportion of patients on clozapine whose antipsychotic polypharmacy brought them into the high-dose range were being monitored appropriately after three audit cycles (the proportion rose from 10% in cycle 1 to 28% in cycle 3). A wide range of additional antipsychotic medications was used.

Clinical implications

Clozapine antipsychotic polypharmacy was prevalent at just below a third of all patients in this review. Prescribers should be alert to the fact that clozapine antipsychotic polypharmacy can push patients into the high-dose range and ensure appropriate monitoring.

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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.
Corresponding author
Sam Wilson (samuelwilson@nhs.net)
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Declaration of interest

None.

Footnotes
References
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Clozapine antipsychotic polypharmacy: audit of use and patient monitoring

  • Sam Wilson (a1), Ross Hamilton (a1), John Callender (a1), Angela MacManus (a1), Sheila Howitt (a2) and Blessing Okpo (a3)...
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eLetters

Cardiovascular monitoring in patients prescribed clozapine

William R Jones, Consultant Psychiatrist
02 March 2014

We were interested to read the recent paper by Wilson et al (1) which highlights the ongoing issue of poor physical health monitoring in patients prescribed clozapine. We recently presented a survey which investigated standards of physical health monitoring in adult patients (n=98) prescribed clozapine against standards set out by Maudsley Guidelines in which we found similarly high rates (53%) of clozapine augmentation and antipsychotic polypharmacy (2). Moreover, we found that cardiovascular monitoring was poor with only 30% having had a baseline electrocardiogram prior to initiation of clozapine. Similarly, only 28% of patients had yearly electrocardiogram monitoring performed once clozapine therapy had been established. Of those patients established on clozapine therapy, 34% were found to have asymptomatic sinus tachycardia which was more commonly seen in patients prescribed additional antipsychotic medication than those prescribed clozapine alone (p <0.001).

Clinical actions in response to asymptomatic sinus tachycardia varied enormously with only 12% of cases having been discussed with local cardiology services.



These findings are of great concern when one considers that clozapine is associated with potentially life-threatening adverse cardiovascular conditions such as myocarditis and cardiomyopathy (3). Whilst tachycardia is commonly seen during the early stages of clozapine treatment occurring in up to 50% of patients, sustained tachycardia, defined as a heart rate > 100 bpm for more than 6 months, can precipitate cardiomyopathy and appears to be an independant risk factor for sudden cardiac death (4). Reducing clozapine dose and the use of rate-limiting drugs such as beta-blockers have been suggested as potential solutions to this problem (5), although these options may not always be clinically appropriate and there appears to be a broad range of approaches in dealing with this.

In response to these findings we have introduced a system whereby initiation of clozapine therapy and its continued prescription by our pharmacy department is contingent on evidence of baseline and continued cardiovascular monitoring. We have also developed a shared care pathway with our local cardiology department ensuring that cardiac monitoring is optimised in this vulnerable patient group and that management of sustained tachycardia is jointly managed by both psychiatric and cardiology services. Information on this shared care pathway is available from the corresponding author.

References:1.Wilson S, Hamilton R, Callender J, MacManus A, Howitt, S, Okpo B. Clozapine antipsychotic polypharmacy: audit of use and patient monitoring. Psychiatric Bulletin 2013; 37: 322-325.

2.Jones WR, Narayana U, Howarth S, Shinners J, Nazar Q. Audit of cardiovascular monitoring in patients prescribed clozapine. Poster session presented at: Royal College of Psychiatrists Faculty of General Adult Psychiatry Annual Conference 2013; Oct 10-11: Manchester, UK.

3.Kilian JG, Kerr K, Lawrence C, Celermajer DS. Myocarditis and cardiomyopathy associated with clozapine. Lancet 1999; 354: 1841-1845.

4.Shinbane JS, Wood MA, Jensen DN, Ellenbogen KA, Fitzpatrick AP, Scheinman MM. Tachycardia-induced cardiomyopathy: a review of animal models and clinical studies. Journal of the American College of Cardiology 1997; 29: 709-715.

5.Young CR, Bowers MB, Manure CM. Management of the adverse effects of clozapine. Schizophrenia Bulletin 1998; 24: 381-390.

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Conflict of interest: None declared

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