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11/13/24, 8\:16 PM Guide | Clozapine counselling

Clozapine counselling

Table of contents

Introduction

This article provides a step-by-step approach to counselling patients about clozapine in an OSCE setting.

Opening the consultation

Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Con
Explain the reason for the consultation\:
“ T o d a y I’ d l i k e t o t a l k t o y o u a b o u t a m e d i c a t i o n c a l l e d c l o z a p i n e , w o u l d t h a t b e o k ?”
.
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their
situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use the
ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
Ideas
“ H a v e y o u h e a r d o f c l o z a p i n e ?”
“ B e f o r e w e s t a r t , a r e y o u a b l e t o p l e a s e t a k e m e t h r o u gh w h a t y o u k n o w a b o u t c l o z a p i n e a l r e a d y ?”
Concerns
“ D o y o u h a v e a n y p a r t i c u l a r w o r r i e s a b o u t s t a r t i n g c l o z a p i n e ?”
Expectations
“ W h a t w e r e y o u h o p i n g w e w o u l d c o v e r t o d a y r e l a t i n g t o c o n s i d e r i n g a t r i a l o f c l o z a p i n e ?”

Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the
consultation.
This should include exploration of the patient’s symptoms and management of schizophrenia so far including hospital
admissions and previous trials of medication including impact, compliance and adverse e
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their speci
situation.
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For more information, see the Geeky Medics guides to schizophrenia and exploring .

What is clozapine?

Clozapine is an antipsychotic medication used in patients who have schizophrenia that is di
resistant.
This means that it is used in those who have not responded to treatment with at least two other antipsychotics (usually one

1
Example
" S o m e t i m e s , w e
s c h i z o p h r e n i a ; s u c h a s h a l l u c i n a t i o n s , p a r a n o i a , d i s o r g a n i z a t i o n o r u n u s u a l b e l i e f s . T h i s c a n m a k e i t d i
l i v e t h e l i v e s t h e y w o u l d l i k e t o .
"
" W h e n p e o p l e h a v e t r i e d a t l e a s t t w o d i
r e f e r t o t h i s a s ' d i
"
.

How to take clozapine

Clozapine comes in tablet form, a liquid option and more recently an orodispersible form. 2
It is not currently available in depot
form.
Clozapine is prescribed at a low dose to start o
doses are not missed. This is because if clozapine is not taken for more than 48 hours the titration process needs to start again.
3
Advantages of clozapine
Given all the information on side e
be easy to overlook the advantages.
Studies have shown that approximately six out of ten people with treatment-resistant schizophrenia will bene
taking clozapine.
There is also research that demonstrated clozapine is superior to olanzapine when preventing suicide attempts in
patients with schizophrenia and schizoa
5
Example
" I n y o u r c a s e , I u n d e r s t a n d t h a t t h i n g s r e m a i n d i
p e o p l e i n t h i s s i t u a t i o n , w e l i k e t o c o n s i d e r u s i n g a n o t h e r m e d i c i n e c a l l e d c l o z a p i n e . W e k n o w t h a t m a n y p e o p l e w h o
h a v e n o t r e s p o n d e d t o o t h e r m e d i c a t i o n w i l l n o t i c e a s i g n i
t h e i m p r o v e m e n t o f d i s t r e s s i n g s y m p t o m s a n d i m p r o v e d f u n c t i o n i n g, w i t h c l o z a p i n e o f t e n h e l p i n g p e o p l e t o b e w e l l
e n o u g h t o l e a v e h o s p i t a l o r l i v e i n d e p e n d e n t l y .
"
" U n f o r t u n a t e l y , t h e r e a r e s o m e i m p o r t a n t , p o t e n t i a l l y s e r i o u s , s i d e-e
u s e d s t r a i g h t a w a y i n a l l p a t i e n t s w i t h s c h i z o p h r e n i a d e s p i t e i t b e i n g e
r e q u i r e s i n c r e a s e d t e s t s a n d m o n i t o r i n g w h i c h I w a s h o p i n g t o c o v e r w i t h y o u t o d a y .
"
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Side e

Side e

Common side e

Common side e
3,6
Sedation\: may improve with time but can consider night-time dosing only
Constipation\: bowel monitoring, high
Tachycardia\: consider cardiology advice as persistent tachycardia could represent a cardiac complication, otherwise beta-
blockers can be used
Weight gain\: dietary advice is important, metformin has also been shown to be e
weight gain
Hypersalivation\: often improves over time, if troublesome for the patient hyoscine can be used
Blood pressure changes\: clozapine can cause both hypotension and hypertension.
Hyperglycaemia\: may require oral hypoglycaemics or insulin.

Rare but serious side e

Clozapine can cause a drop in white cells, speci
A small drop in these numbers of cells is called neutropenia, which a
more signi
4
Due to this risk and the subsequent risk of developing a severe infection, there are strict monitoring protocols for patients
taking clozapine. Patients also need to be advised to seek urgent medical assessment if they develop
Clozapine also lowers the seizure threshold and therefore patients can develop seizures, especially when clozapine is
prescribed at higher doses. Those who require high doses are often prescribed a prophylactic anticonvulsant such as sodium
valproate.
3
Cardiac complications including myocarditis and cardiomyopathy have been associated with clozapine therapy. These should
be considered in any patient who develops persistent tachycardia at rest, chest pain, abnormal rhythms, palpitations or
evidence of heart failure.
3
If cardiac complications are suspected, patients should undergo a physical examination, ECG, laboratory investigations
including troponin and CRP. A cardiology opinion should be sought, and an echocardiogram may be required.
Constipation is a common side e
developing an ileus and bowel obstruction.
3

Monitoring

All antipsychotics require baseline investigations and then subsequent monitoring.

Baseline investigations

Baseline investigations usually include\:
7
ECG
Blood pressure and pulse
Calculation of body mass index (BMI)
Laboratory investigations\: FBC, U&Es, LFTs, prolactin, HbA1c and lipids. For clozapine, a baseline troponin is also requested.

Clozapine monitoring

Due to the risk of serious side e
initiation and titration of clozapine and regular blood tests.
8
During the
to fortnightly after 18 weeks and then monthly after one year.
8
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All patients in the United Kingdom taking clozapine will be registered with the service that manufactures their type of
treatment and medication will only be dispensed if blood tests are within acceptable limits.
Plasma levels of clozapine are also monitored in some circumstances. This includes when poor compliance is suspected,
when high doses are required and when their smoking status changes. Levels of clozapine can rise signi
reduction and cessation of cigarette smoking.
3
Example
" W e k n o w t h a t i n s o m e c a s e s p e o p l e e x p e r i e n c e s e r i o u s s i d e e
w e c a r e f u l l y m o n i t o r p a t i e n t s t a k i n g t h i s m e d i c a t i o n . I n i t i a l l y , w e r e q u i r e s o m e b a s e l i n e i n v e s t i ga t i o n s i n c l u d i n g y o u r
w e i g h t , h e i g h t , a t r a c i n g o f y o u r h e a r t , p h y s i c a l o b s e r v a t i o n s a n d b l o o d t e s t s . F o l l o w i n g t h i s , i t i s i m p o r t a n t t h a t y o u h a v e
w e e k l y b l o o d t e s t s f o r t h e
r e s p o n s i b l e f o r
"
" R a r e l y , c l o z a p i n e w i l l c a u s e a d r o p i n t h e n u m b e r o f t h e s e w h i t e c e l l s a n d i t i s i m p o r t a n t t h a t t h i s i s d e t e c t e d e a r l y . T h e
r i s k i s h i g h e r w h e n c l o z a p i n e i s
n e e d t o h a v e r e g u l a r b l o o d t e s t s f o r a s l o n g a s y o u r e m a i n o n c l o z a p i n e , a n d f o r a s h o r t p e r i o d a f t e r w a r d s i f y o u s t o p i t . I t
i s i m p o r t a n t t o l e t y o u r c a r e c o o r d i n a t o r k n o w i f y o u e x p e r i e n c e a n y
t o b e c h e c k e d .
"
" C l o z a p i n e c a n a l s o r a r e l y c a u s e h e a r t p r o b l e m s w h i c h i s w h y a h e a r t t r a c i n g i s c o m p l e t e d b e f o r e s t a r t i n g w i t h r e gu l a r
c h e c k s o f y o u r h e a r t r a t e . I f y o u n o t i c e a n y c h e s t p a i n , p a l p i t a t i o n s o r s w o l l e n a n k l e s i t i s i m p o r t a n t t o i n f o r m y o u r c a r e
t e a m .
"
" W e a l s o k n o w t h a t c l o z a p i n e i n c r e a s e s t h e l i k e l i h o o d o f c o n s t i p a t i o n . I f c o n s t i p a t i o n b e c o m e s s e v e r e , p e o p l e c a n b e a t
r i s k o f b o w e l p r o b l e m s . F o r t h i s r e a s o n , w e s u gge s t t h a t y o u m o n i t o r y o u r b o w e l s a n d c a n p r o v i d e a s t o o l c h a r t i f t h i s
w o u l d h e l p . I f y o u d o n o t i c e d i
"

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Finally, thank the patient for their time and o
Royal College of Psychiatrists has a patient information lea on antipsychotics, including clozapine.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Nwaorima Kamalu

References

1. NICE. P s y c h o s i s a n d s c h i z o p h r e n i a i n a d u l t s \: p r e v e n t i o n a n d m a n a ge m e n t . Published February 2014. Available from\: [LINK]
2. Choice and medication. M e d i c a t i o n \: c l o z a p i n e . Accessed November 2021. Available from\: [LINK]
3. Sussex Partnership NHS Trust. P r o c e d u r e a n d G u i d a n c e f o r t h e u s e o f C l o z a p i n e . Published August 2015. Available from\: [LINK]
4. Rotherham Doncaster and South Humber NHS Foundation Trust. C l o z a p i n e , I n f o r m a t i o n f o r s e r v i c e u s e r s a n d c a r e r s . Published
November 2011. Available from\: [LINK]
5. 6. Meltzer et al. C l o z a p i n e t r e a t m e n t f o r s u i c i d a l i t y i n s c h i z o p h r e n i a \: I n t e r n a t i o n a l S u i c i d e P r e v e n t i o n T r i a l ( I n t e r S e P T ) . Published
January 2003. Available from\: [LINK]
Liu et al. M e t f o r m i n f o r t r e a t m e n t o f c l o z a p i n e-i n d u c e d w e i gh t ga i n i n a d u l t p a t i e n t s w i t h s c h i z o p h r e n i a \: a m e t a-a n a l y s i s .
Published December 2015. Available from\: [LINK]
7. NICE. P s y c h o s i s a n d s c h i z o p h r e n i a \: W h a t m o n i t o r i n g i s r e q u i r e d ? . Published September 2021. Available from\: [LINK]
https\://app.geekymedics.com/osce-guides/counselling/clozapine-counselling/ 4/511/13/24, 8\:16 PM Guide | Clozapine counselling
8. NICE BNF. C l o z a p i n e . Accessed November 2021. Available from\: [LINK]
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/clozapine-counselling/ 5/5