<div class="title" data-jats-encoding-type="nlm-3.0">Mental Health Clinician</div> Volume 1: Issue 5

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Clozapine: Underused and misunderstood

PharmD, BCPS, BCPP

“Why Not Clozapine?” asked Kelly and colleagues over four years ago in a Clinical Schizophrenia article.¹ Apparently, few heard the question and still fewer answered. In 2011, over 20 years since clozapine was marketed in the U.S., its use is at an all-time low. In 1999, 11% of second generation antipsychotic prescriptions in the U.S. were for clozapine. Today, only 2–3% of antipsychotic prescriptions are for clozapine.¹ This is despite overwhelming evidence of its effectiveness for treatment-resistant schizophrenia, suicide prevention in schizophrenia, reductions in hospitalizations, and other pharmacoeconomic data supporting the use of clozapine. Dr. Herbert

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MHC clozapine toolbox

PharmD, BCPP

DOI: 10.9740/mhc.n87735

The toolbox beginning on the next page was compiled to provide several documents that will assist you with treating your clozapine patients. It includes a suggested protocol for initiating someone on clozapine (see Figure 1). We have also included guidelines for CBC monitoring (see Table 1), at initiation and beyond, as well as monitoring recommendations for when an interruption in treatment occurs (see Figure 2). Since constipation is a major adverse event associated with the use of clozapine, attached you will find an overview of both prevention and treatment of constipation compiled by Beth

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Clozapine-induced gastrointestinal hypomotility: More than just constipation

Pharm.D., M.S.Phr., BCPP

DOI: 10.9740/mhc.n87491

CASE

A 60 y.o. male with longstanding paranoid schizophrenia was admitted from a local group home with abdominal pain and distention of several days in duration and vomiting for the previous 24 hours. He had been seen in the family practice clinic at this academic medical center on the day prior to admission for similar complaints and magnesium citrate was recommended. An abdominal plain film from that visit was consistent with ileus and moderate stool load. The patient was admitted to the emergency treatment center later that day with new-onset vomiting. He was sent home after three soap suds enemas

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Fostering the use of clozapine in the severely mentally ill through academic detailing

Pharm.D.,

Pharm.D., and

Pharm.D.

DOI: 10.9740/mhc.n87507

Academic detailing is an educational program in which independent researchers and clinicians evaluate available literature to develop up-to-date, unbiased, evidence-based recommendations for a given therapeutic area. Pharmacists, nurses, and physicians trained as academic detailers then disseminate this information to providers. This is one means to foster the greater use of clozapine in patients with treatment-resistant schizophrenia. The Veterans Health Administration (VHA) Academic Detailing Service meets with mental health providers at each facility to identify barriers and healthcare systems solutions, provide feedback about prescribing and patterns of care, and develop and distribute educational materials to improve veteran health outcomes. Preliminary results include a reduction in polypharmacy antipsychotic use from 17% of patients on antipsychotics to 12.2% of patients (p<0.001). Although there was a numeric increase clozapine new starts in the 5-month interim analysis, the increase was not significant in this analysis. Analysis for 12-month data is underway. The early success of this program demonstrates there may be opportunity for this type of educational intervention in the Veterans Affairs Healthcare System.

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Questions for pharmacist providers in clozapine clinics: Zacher

PharmD, BCPP

DOI: 10.9740/mhc.n87492

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

About 5 years. There was an established clozapine clinic when I started, so I took over.

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE YOU HAD?

I completed a Psychiatric Pharmacy Residency at the Louis Stokes Cleveland VAMC in 2004–2005. In 2006, I took the BCPP exam and became board certified in psychiatric pharmacy.

WHAT IS THE GREATEST IMPACT YOU HAVE HAD ON YOUR PATIENTS?

Since I coordinate all of the blood draws, and I monitor the results, I feel

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Questions for pharmacist providers in clozapine clinics: Mascarenas

Pharm.D., BCPP

DOI: 10.9740/mhc.n87529

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

I have been a clinical pharmacy specialist with the VA since 2003. When I first started, the clozapine procedures for our facility were not clear, including enrollment, transfer, and discontinuation, and the required monitoring was not being submitted to the VA's Clozapine Coordinating Center. I developed the clozapine clinic as a way to organize our system and to make sure our patients were being monitored properly. Eventually I became the clozapine treatment team co-chair for South Texas.

HOW DID YOU GET TO WHERE YOU

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Questions for pharmacist providers in clozapine clinics: Ott and Williams

PharmD, BCPP and

PharmD

DOI: 10.9740/mhc.n87934

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

Dr. Ott: My clinic has been in operation since May 2009. I was invited by the attending psychiatrists to be a part of the launch, as well as a continuing team member for the clinic with a collaborative practice agreement. My role continues to grow as our research program expands, studies often include me as a co-investigator with similar study responsibilities to our physicians, including research and clinical visits and rating scales.

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE

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Questions for pharmacist providers in clozapine clinics: Boerth

Pharm.D., BCPP

DOI: 10.9740/mhc.n87500

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

I've been operating the clozapine clinic at our Medical Center for over 7 years now. The clinic already existed before I was hired. I was given the option of running the clinic, and since it was the first clinic opportunity presented to me, I gladly accepted.

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE YOU HAD?

I've been working as a pharmacist in mental health for over 10 years. I completed a 1-year residency in psychiatric pharmacy practice at the

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Case Report: The clinical implications of clozapine and cigarette smoking

Pharm.D. and

Pharm.D., BCPP

DOI: 10.9740/mhc.n87936

INTRODUCTION

Cigarette smoking is prevalent among psychiatric patients, with rates several times higher than the general population. As an example, up to 80% of schizophrenic patients smoke cigarettes.¹ Clozapine is extensively metabolized by cytochrome P450 isoenzyme 1A2 and polycyclic aromatic hydrocarbons (PAHs) present in cigarette smoke are thought to induce CYP 1A2.¹ ² Therefore concurrent smoking with clozapine can potentially lead to decreased clozapine levels and decreased efficacy, while smoking cessation can potentially lead to increased levels and toxicity. Enzyme induction has been reported to result in a 20 to 40% lower mean clozapine concentration in

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Psychiatry in the cinema

PharmD, MS, BCPP,

Pharm.D. student, and

PharmD, BCPP

DOI: 10.9740/mhc.n86989

The portrayal of mental illness in film has been a favorite topic of discussion on the College of Psychiatric and Neurologic Pharmacists listserv for many years. This movie review compares and contrasts two such films, one a classic (One Flew Over the Cuckoo's Nest) and the other (Shutter Island) a relatively new addition to the filmographic registry of the psychiatric genre. Further, this review is provided from two different perspectives-that of a veteran psychiatric pharmacist and a fourth year Pharm.D. student.Spoiler Alert- if you have not seen these pictures, some significant aspects of the

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Book Review: Case studies: Stahl's essential psychopharmacology

PharmD., BCPP and

CPNP POP Committee Member

DOI: 10.9740/mhc.n87330

Amy Jones reviews Case Studies: Stahl's Essential Psychopharmacology.

CPNP members maintain a suggested reading list to provide information on peer recommended resources and convenient access to the highest quality neuropsychopharmacology publications. A reminder that if you shop with CPNP, by following the links below to Amazon, a small commission will be paid to CPNP which helps to financially support our mission to improve the minds and lives of individuals with psychiatric and/or neurologic disorders.

You can help grow this list of resources by suggesting a book.

Book: Case Studies: Stahl's Essential Psychopharmacology

PRODUCT DESCRIPTION:

This

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Your engagement is critical to CPNP and to the profession

Pharm.D., M.S., BCPP

DOI: 10.9740/mhc.n86980

Stop me if you have heard this story already. I am still perseverating on volunteerism! CPNP is presently recruiting volunteers for 2012 committees and activities. Although we have volunteer opportunities year-round, we are seeking Recertification, Review course and Mental Health Clinician Editorial Board applicants. As well, we will be recruiting 2012 committee members through the end of November. Simply let us know your preferences in your volunteer profile which is now available and editable year round through My CPNP at cpnp.org. As President-Elect Rex Lott has recently noted, the contacts and skills that you gain can, in the

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CPNP Announcements

DOI: 10.9740/mhc.n86987

REDUCING CLOZAPINE-INDUCED HYPERSALIVATION

This clinical pearl by Gurprit Lamba, MD, and James M. Ellison, MD, MPH was published in the September 2011 issue of Current Psychiatry.

View this month's toolbox to access the Current Psychiatry pearl, MHC's strategies to treat clozapine hypersalivation, and other useful tools.

A reminder that a special subscription price is available to Current Psychiatry, a monthly peer-reviewed publication, and the leading source of practical, evidence-based information for healthcare professionals treating psychiatric patients. Thanks to the CPNP partnership with Current Psychiatry, CPNP members can receive a year

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Clozapine: Underused and misunderstood

MHC clozapine toolbox

Clozapine-induced gastrointestinal hypomotility: More than just constipation

CASE

Fostering the use of clozapine in the severely mentally ill through academic detailing

Questions for pharmacist providers in clozapine clinics: Zacher

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE YOU HAD?

WHAT IS THE GREATEST IMPACT YOU HAVE HAD ON YOUR PATIENTS?

Questions for pharmacist providers in clozapine clinics: Mascarenas

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

HOW DID YOU GET TO WHERE YOU

Questions for pharmacist providers in clozapine clinics: Ott and Williams

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE

Questions for pharmacist providers in clozapine clinics: Boerth

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S?

HOW DID YOU GET TO WHERE YOU ARE TODAY? WHAT TRAINING HAVE YOU HAD?

Case Report: The clinical implications of clozapine and cigarette smoking

INTRODUCTION

Psychiatry in the cinema

Book Review: Case studies: Stahl's essential psychopharmacology

PRODUCT DESCRIPTION:

Your engagement is critical to CPNP and to the profession

CPNP Announcements

REDUCING CLOZAPINE-INDUCED HYPERSALIVATION

Pharmacist administration of long-acting injectable medications for substance use disorders: A scoping review

Transitions of care: Assessment of adherence to long-acting injectable antipsychotic treatment following discharge from inpatient psychiatry

Use of atypical antipsychotics in individuals with anorexia nervosa

Potential changes impacting psychiatric pharmacy by 2030

A model for timely dissemination of critical information: Clozapine toxicity during the COVID pandemic