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Clozapine is often considered the gold standard for the treatment of schizophrenia. Clinical guidelines suggest a gradual titration over 2 weeks to reduce the risks of adverse events such as seizures, hypotension, agranulocytosis, and myocarditis. The slow titration often delays time to therapeutic response. This raises the question of whether, in some patients, it may be safe to use a more rapid clozapine titration. The following case illustrates the potential risks associated with the use of multiple antipsychotics and rapid cloza-pine titration. We present the case of a young man with schizophrenia who developed life threatening neuroleptic malignant syndrome (NMS) during rapid clozapine titration and treatment with multiple antipsychotics. We were unable to find another case in the literature of NMS associated with rapid clozapine titration. This case is meant to urge clinicians to carefully evaluate the risks and benefits of rapid clozapine titration, and to encourage researchers to further evaluate the safety of rapid clozapine titration. Rapid clozapine titration has implications for decreasing health care costs associated with prolonged hospitalizations, and decreasing the emotional suffering associated with uncontrolled symptoms of psychosis. Clozapine is considered the most effective antipsychotic available thus efforts should focus on developing strategies that would allow for safest and most efficient use of clozapine to encourage its utilization for treatment resistance schizophrenia.

Clozapine is a well-known antipsychotic medication licensed for treatment-resistant schizophrenia, but there is limited research available to suggest its efficacy in the context of personality disorder and intellectual disabilities presenting with high-risk behaviour with or without psychotic symptoms. The purpose of this paper is to raise awareness of the benefits of using clozapine in patients with intellectual disabilities and personality disorder that present with a complex picture of serious risk of harm to both their life and the lives of others.

The authors present five patients with intellectual disabilities and serious life-threatening challenging behaviour whom were started on clozapine as part of their multidisciplinary treatment plan to manage their presentation. The authors completed baseline assessment of five main symptom domains and then repeated this assessment following treatment with clozapine.

In all five cases use of clozapine was objectively associated with an improvement in symptomatology, quality of life and a safe transfer to the community.

The findings suggest that judicious use of clozapine could be considered as one of the effective pharmacological strategies in the management of patients with intellectual disabilities and personality disorder who present with serious life-threatening challenging behaviours.

There is a considerable disparity between clinical practice and recommendations based on meta-analyses of antipsychotic polypharmacy in clozapine resistant schizophrenia. For this reason, we investigated the clinical response to reducing the use olanzapine that had been previously added on clozapine treatment among seriously ill hospitalized patients. In a randomized controlled trial with crossover design, we studied volunteer patients (N=15) who had olanzapine added on to clozapine in a state mental hospital. Clozapine monotherapy was just as effective as clozapine-olanzapine therapy, according to results from Clinical Global Impression Scale and Global Assessment of Functioning as primary outcome measures. Polypharmacy is widely used in treating schizophrenia, and usually, add-on medications are started because of worsening of the clinical state. A major confounding feature of these add-ons is whether observed improvements are caused by the medication or explained by the natural fluctuating course of the disorder. The present study, in spite of its small size, indicates the necessity of reconsidering the value of polypharmacy in treating schizophrenia.

The purpose of this paper is to review the efficacy of atypical antipsychotics in combination with clozapine. Previous meta-analyses have assessed the use of both typical and atypical antipsychotics in combination with clozapine, combination treatment being withheld only for those patients deemed treatment resistant.

Outcomes assessed included: positive, negative and overall symptom score. The total numbers of participants (n=588) were scored using the Positive and Negative Symptom Scale/the Brief Psychiatric Rating Scale and effect sizes were used to judge the efficacy of the combination treatments. Data gained from the ten randomized, double blind, placebo controlled trials were analysed using the R statistical software.

The effect sizes gained from analysis showed a small benefit of combination therapy over clozapine monotherapy. Therefore, it is the recommendation of this analysis that alternative avenues be sought in order to treat patients who have a sub-optimal response to clozapine with a combination other than two second generation antipsychotics.

The initial trials search unveiled 1,412 studies. After the inclusion and exclusion criteria were applied, ten trials were used in this meta-analysis.

The recommendation of this analysis that alternative medications be sought in order to treat patients who have a sub-optimal response to clozapine with a combination other than two second generation antipsychotics. This route should only be used once all other treatment options have been exhausted.

This meta-analytical study looks specifically at the combination of atypical antipsychotics with clozapine in comparison to clozapine monotherapy. This work extends existing meta-analysis by incorporating data from more recent trials.

The aim of this study is to test the hypothesis that Clozapine reduces rates of self injury and the use of restraint in a medium secure setting in female patients who have a diagnosis of borderline personality disorder (BPD) and mild learning disability.

A retrospective method of data collection was used with a requirement of six months baseline data on rates of self injury and the use of restraint. Patients were required to remain on Clozapine for a minimum of six months.

The mean number of incidents of self injury in the six months prior to Clozapine was 20.75 (SD 8.8) and 13.5 (SD 4.51) in the six months following Clozapine, a reduction of 35 per cent. The mean number of incidents of restraint in the six months prior to Clozapine was 17.75 (SD 6.86) compared with 9.25 (SD 4.96) in the six months following commencement of Clozapine therapy, a reduction of 48 per cent. The results were analysed using the paired t‐test and the difference between the means (self injury and use of restraint) was not statistically significant. This study demonstrates a reduction in the rates of self injury and use of restraint in women with a diagnosis of BPD when treated with Clozapine which was clinically significant although not statistically significant.

The authors are not aware of any published articles on the use of Clozapine in women with BPD and co‐morbid learning disability.

The use of long-term anti-psychotic medication for borderline personality disorder contravenes prescribing guidelines in the UK. There is evidence to suggest clozapine can be beneficial yet anecdotally it is prescribed almost exclusively in locked settings. A single study suggests a substantial proportion of psychiatrists disapprove of this practice. The purpose of this paper is to articulate concerns about the use of clozapine for “BPD” that are absent from current literature.

This paper summarises the reflections and experiences of the authors lived experience, academic and clinical backgrounds.

The published literature is uniformly positive when describing the prescription of clozapine for those diagnosed with BPD; however, this in no way reflects the experience of the authors. There is no body of material reflecting a study showing that a substantial number of psychiatrists have issues with this practice.

While it is a fact that there is a discrepancy between psychiatrists attitudes towards clozapine prescription for “BPD” and the published literature, the described concerns in this paper are based solely on the authors’ experiences and observations.

Those seeking literature to articulate concerns about the use of clozapine with this population will likely be disheartened by the paucity of published literature.

To the best of the authors’ knowledge, this paper is the first to raise substantial concerns about the use of clozapine for those diagnosed with “BPD” and the circumstances in which it is prescribed.

This article describes the practical steps needed to establish and maintain patients on clozapine within secure psychiatric services, particularly where patients have a history of non‐adherence to treatment. The role of psychiatric nurses in creating a climate of therapeutic optimism is stressed. A number of techniques which optimise adherence are described.

Clozapine, whilst associated commonly with a transient and benign increase in liver enzymes, has also been associated with varying presentations of hepatitis in existing case reports. This report describes what we believe to be the first documented case of acute liver injury and pleural effusion associated with clozapine, resolving after cessation of the agent. The case supports existing literature in advocating a high index of suspicion, particularly in the 4-5 weeks following clozapine initiation, when considering nonspecific clinical symptoms and signs.

The purpose of this paper is to study the corrosion inhibition performance of an eco-friendly drug clozapine on the corrosion of copper in 1.0 M nitric acid and 0.5 M sulfuric acid solutions.

The corrosion inhibition nature of inhibitor molecule was evaluated by weight loss, electrochemical impedance spectroscopy and potentiodynamic polarization studies. An attempt was made to correlate the molecular properties of neutral and protonated forms of inhibitor molecule using quantum chemical calculations. The effect of temperature on the corrosion inhibition efficiency was also studied using electrochemical impedance spectroscopy. The potential of zero charge was determined to explain the mechanism of corrosion inhibition.

The studies on corrosion inhibition performance of clozapine showed that it has good corrosion inhibition efficiency on the corrosion of copper in 1.0 M nitric acid and 0.5 M sulfuric acid solutions. The adsorption of clozapine molecules onto the copper surface obeyed the Langmuir adsorption isotherm. The value of free energy of adsorption calculated is very close to −40 kJmol⁻¹, indicating that the adsorption is through electrostatic coulombic attraction and chemisorption. The decrease in the value of energy of activation with the addition of inhibitor also shows the chemisorption of the inhibitor on the metal surface. The potential of zero charge and quantum chemical studies confirmed that the protonated molecules also get involved in the corrosion inhibition process through physisorption.

The present work indicates that clozapine can act as a good corrosion inhibitor for the corrosion of copper in acid media.

Prison settings have limited resources, and it is of particular interest to analyze which antipsychotics are commonly prescribed in these conditions and to determine the prevalence of the adverse effects.

A cross-sectional, epidemiological survey was used to measure the prevalence of antipsychotic prescribing among adult prisoners in Sremska Mitrovica Prison in 2020.

The prevalence of antipsychotic use was 7.58%. The most commonly prescribed antipsychotic was clozapine (45.36%), but also olanzapine, haloperidol and risperidone were prescribed. The incidence of extrapyramidal adverse effects was nonexistent and the metabolic parameters did not differ between participants using metabolic syndrome–inducing antipsychotics and those who were prescribed metabolically inert medications. The prescribed doses were lower compared with the recommended.

This research includes certain points that should be cautiously considered. First, the data were cross-sectional and the findings did not provide causal interpretations. Second, the data are from a single penitentiary institution, albeit the largest in the country; however, that may affect the generalizability of the findings. Third, because the included subjects were not hospitalized, some laboratory analyses were not available, according to the local regulations, and thus the prevalence of metabolic syndrome could not be precisely determined.

The prevalence of the antipsychotic use in prison environment is significantly higher than in general population. The most frequently prescribed antipsychotics are clozapine and olanzapine. The prevalence of adverse effects is rare, however, that is possibly due to low doses of the prescribed antipsychotics. The list of therapeutic options available to the incarcerated persons in this facility is also limited. The list of available antipsychotics does not include some atypical antipsychotics with more favorable safety and tolerability profile, such as aripiprazole or cariprazine. Long-acting antipsychotic injectables were also not available to these patients. Laboratory analyses are not regularly conducted and do not include some essential parameters such as lipid status or differential blood count. Low-dose antipsychotics for behavioral symptoms appears to be well tolerated under prison conditions where adherence is assured. It is effective during the prison stay but long-term effects, especially after release from prison, had not been studied.

This paper advocates for better quality of health care in this correctional facility: more therapeutic options and better laboratory monitoring. The authors justify the use of clozapine in this settings due its benefits in reducing violence and aggression; however, further research would be necessary to clarify does the use of clozapine in incarcerated persons cause behavioral improvements that could result in shorter incarcerations, less recidivism and better quality of life.

To the best of the authors’ knowledge, this is the first insight of the antipsychotic prescribing practice in Serbia. There is very limited data on prisoners’ health care, especially mental health care, in Balkan countries. The antipsychotic prescribing pattern in this sample is characterized with higher than expected clozapine use, but without expected adverse effects.