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Clozapine
Aka: Clozapine, Clozaril
- Class
- Atypical Antipsychotic (Second Generation agent)
- Neuroleptic
- Dibenzodiazepine Antipsychotic
- Precautions
- Not a first line Antipsychotic: See Disadvantages below
- Only providers in Clozapine REMS Program can prescribe
- Each patient on Clozapine must be registered with the program
- Requires regular submission of Absolute Neutrophil Counts
- FDA black box warnings
- Agranulocytosis
- Seizure risk, Myocarditis
- Orthostatic Hypotension
- Increased mortality in elderly
- Indications
- Refractory Schizophrenia
- Suicidal behavior in Schizophrenia
- Psychosis in the elderly (not FDA approved)
- Bipolar Disorder (not FDA approved)
- Dosing
- Adults
- Initial: 12.5 mg PO qd or bid
- Titrate slowly upwards in increments of 25-50 mg/day
- Target dosing: 300-450 mg/day
- Maximum dose: 900 mg/day
- Elderly
- Initial: 6.5 PO qd
- Titrate slowly upwards in increments of 25 mg/day
- Maximum dose: 450 mg/day
- Cost
- Even generic costs >$250 per month
- Disadvantages
- Agranulocytosis has high mortality
- Higher risk of Diabetes Mellitus and weight gain
- Hypertriglyceridemia
- Adverse Effects
- Anticholinergic Symptoms
- Agranulocytosis
- Hypotension (alpha-Adrenergic Receptor blockade)
- Tachycardia
- Hyperthermia
- Hyperglycemia including development of Diabetes Mellitus
- Seizures
- Sialorrhea
- Weight gain
- Sedation
-
Drug Interactions
- Increase Antipsychotic levels (toxicity risk): Monitor for toxicity
- Grapefruit juice
- Caffeine
- Cimetidine
- Ciprofloxacin
- Citalopram
- Erythromycin
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
- Decrease Antipsychotic levels (lower efficacy)
- Barbiturates
- Carbamazepine
- Phenytoin
- Nicotine
- Rifampin
- Monitoring
- See Antipsychotic
- Absolute Neutrophil Counts
- Resources
- Clozapine REMS Program
- https://www.clozapinerems.com/CpmgClozapineUI/home.u
- References
- (2015) Presc Lett 22(11): 65