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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 262-263

Clozapine prescribing pattern in a 10-year-old community psychiatry clinic in South India


1 Department of Neuropsychiatry, Iqraa International Hospital and Research Centre, Kozhikode, Kerala, India
2 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission20-Dec-2019
Date of Decision15-Feb-2020
Date of Acceptance28-Feb-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. N A Uvais
Department of Neuropsychiatry, Iqraa International Hospital and Research Centre, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_127_19

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How to cite this article:
Uvais N A, Sreeraj V S. Clozapine prescribing pattern in a 10-year-old community psychiatry clinic in South India. Indian J Soc Psychiatry 2020;36:262-3

How to cite this URL:
Uvais N A, Sreeraj V S. Clozapine prescribing pattern in a 10-year-old community psychiatry clinic in South India. Indian J Soc Psychiatry [serial online] 2020 [cited 2022 Jan 26];36:262-3. Available from: https://www.indjsp.org/text.asp?2020/36/3/262/296257



Sir,

Clozapine is the most effective drug in treatment-resistant schizophrenia, and it also has a clinical superiority over both first- and second-generation antipsychotics in preventing suicide, reducing aggressive behavior, and minimizing extrapyramidal side effects.[1] Furthermore, clozapine use has been shown to reduce discontinuation, re-hospitalization, and polypharmacy with other antipsychotic agents.[2]

Although most of the clinical guidelines recommend initiation of clozapine in treatment-resistant schizophrenia at the earliest phase of treatment resistance, surveys indicate that clinicians are reluctant to prescribe it due to concerns about the adverse effects, including agranulocytosis and metabolic syndrome.[3] Regular hematological monitoring which may not be feasible in rural clinics also could make its use limited, especially in community psychiatry practice.[4] The profile of clozapine users in community treatment settings is not well described. In this study, we describe the profile of patients and prescription histories in a community-dwelling population treated with clozapine at a 10-year-old community psychiatry clinic in South India. The permission for the study was taken from the office-bearers of the clinic.

A retrospective chat review was conducted by accessing the treatment records of patients attending the community psychiatry clinic during December 2017. The community psychiatry clinic was run by the local palliative clinic since 2008 and provides multidisciplinary services to patients with severe mental illnesses and their families, through professionals and community volunteers. The clinic accepts adult patients with poor financial resources and provides regular medical and rehabilitative services free of cost. Medical records of all the patients who were on clozapine therapy at the time of data collection were included. Sociodemographic and clinical data were recorded.

Of the 83 patients attending the community psychiatry clinic, 7 (8.43%) were on clozapine at the time of the data collection. The age of clozapine users ranged from 33 to 60 years (mean: 48; standard deviation [SD]: 9.64) and 85.7% were males. Of the seven patients, five (71.4%) were diagnosed with schizophrenia and the rest were diagnosed with psychosis not otherwise specified. Of the seven patients, only two (28.57%) patients were started on clozapine from the community clinic. In the first case, clozapine was started at 25 mg/day and hiked to 50 mg after a week. In the second case, clozapine was started at 50 mg and hiked to 100 mg after 2 weeks. The reason for switching to clozapine in both cases was tardive dyskinesia with long-acting injectable antipsychotic agents. Rest were already on clozapine at the time of intake to the clinic, and it was continued. The dose of clozapine ranged from 25 to 450 mg/day (mean: 282.14; SD: 141.95). Three (42.86%) patients were on polypharmacy (2 patients were on fluoxetine with clozapine, and one patient was on sodium valproate and olanzapine with clozapine). Adverse effects were recorded in two patients (constipation and hypersalivation). Two (28.57%) patients were diagnosed with diabetes mellitus (DM) and were on medications for DM.

This retrospective chart review provides a snapshot of the patients on clozapine therapy from a community psychiatry clinic. It was observed that only 8.43% of the patients were on clozapine, of which only 28.57% of the patients were started on clozapine from the community psychiatry clinic. These findings indicate the hesitancy to switch patients to clozapine, probably due to the concerns regarding adverse events, and the difficulty in titrating drugs with hematological monitoring in rural community settings. Furthermore, the clozapine titration was done more cautiously than generally recommended in the treatment guidelines, indicating the difficulty in titrating drugs in a community setting where the patients take medication unsupervised at their home. Although there are specific guidelines for titrating clozapine on an outpatient basis, it may not be feasible in a setting with limited workforce and poor educational background of the patients and their caregiver.

The study results also showed that most of the patients on clozapine tolerated the drug well and reported only minor side effects, such as constipation or hypersalivation, and no one needed switching to any other agent after clozapine use or needed hospitalization for relapse. However, a significant proportion of clozapine users were diagnosed with DM in our study, indicating the need for monitoring metabolic parameters closely while a patient is on clozapine.

Our results are limited by the accuracy and completeness of the information contained in the medical records and by the small sample size. However, the observational approach used provides real-world information regarding the use of clozapine in a 10-year community psychiatry clinic in South India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thien K, O'Donoghue B. Delays and barriers to the commencement of clozapine in eligible people with a psychotic disorder: A literature review. Early Interv Psychiatry 2019;13:18-23.  Back to cited text no. 1
    
2.
John AP, Ko EK, Dominic A. Delayed initiation of clozapine continues to be a substantial clinical concern. Can J Psychiatry 2018;63:526-31.  Back to cited text no. 2
    
3.
Xu SW, Dong M, Zhang Q, Yang SY, Chen LY, Sim K, et al. Clozapine prescription pattern in patients with schizophrenia in Asia: The REAP survey (2016). Psychiatry Res 2019. pii: S0165-1781 (18) 32218-2.  Back to cited text no. 3
    
4.
Farooq S, Choudry A, Cohen D, Naeem F, Ayub M. Barriers to using clozapine in treatment-resistant schizophrenia: Systematic review. BJPsych Bull 2019;43:8-16.  Back to cited text no. 4
    




 

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