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A Case Report of Complex Clozapine Initiation Despite Contraindications

Published online by Cambridge University Press:  19 July 2023

G. Dumais-Lévesque*
Affiliation:
Psychiatry and Neurosciences, University Laval University Institute of Mental Health in Quebec
L. Béchard
Affiliation:
University Institute of Mental Health in Quebec Pharmacy Faculty, University Laval CERVO Research Center, Quebec, Canada
E. Malenfant
Affiliation:
University Institute of Mental Health in Quebec Pharmacy Faculty, University Laval
M.-F. Demers
Affiliation:
University Institute of Mental Health in Quebec Pharmacy Faculty, University Laval CERVO Research Center, Quebec, Canada
A.-P. Bouffard
Affiliation:
Psychiatry and Neurosciences, University Laval University Institute of Mental Health in Quebec
*
*Corresponding author.

Abstract

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Introduction

Clozapine is well known for its unique efficacy in treatment-resistant schizophrenia and to reduce violent behaviour. Unfortunately, life-threatening adverse reactions including ileus, myocarditis and agranulocytosis can hinder its use. In this context, some clinicians may be reluctant to initiate clozapine in patients who are prone to these adverse drug reactions.

Objectives

To describe a complex clozapine initiation despite the presence of serious adverse effects and contraindications. The management of these adverse events, using effective multidisciplinary team leadership strategies, will also be described.

Methods

A case report will be presented. The challenges faced while using clozapine and strategies implemented to pursue the use of this medication will be described.

Results

A young black man with severe first episode psychosis was admitted to the early intervention outpatient clinic in Québec, Canada. Multiple aggression and critically disorganized behaviour prompted patient transfer to a specialized long-term care unit. Given the severity of the resistant disease and after a shared decision-making process with the family, clozapine was introduced despite ethnic neutropenia (down to 0,2 X 109/L) and idiopathic cerebral lesions. Both gave rise to multiple concerns. A specific hematological surveillance protocol was designed. Facing multiple severe neutropenia episodes, the use of prophylactic granulocyte colony-stimulating factor (300 mcg SC weekly) was added after literature review and a favourable consult of both pharmacist and hematologist. Cardiac enzyme elevation also requested specialized investigation and follow-up. Specialized educators, social workers, and nursing all needed to be deeply involved in the treatment process and team coordination requested strong team building capacities. After 6 months, the patient is now taking clozapine 325 mg daily and his symptomatology has sufficiently reduced to allow hospital leave. The patient is now engaged in his recovery process.

Conclusions

Using an evidence-based approach, promoting expertise from multiple healthcare professionals, and allowing a substantial amount of time to develop team cohesion were all crucial elements of this success story.

Disclosure of Interest

None Declared

Type
Abstract
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of the European Psychiatric Association
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