An updated clozapine treatment guide against clozaphobic attitudes

Abstract

In recent years, clozapine-related publications are gradually increasing. Despite all the new generation of antipsychotics, one-third of patients with scizophrenia are still treatment-resistant. Clozapine is a unique and gold standard antipsychotics with FDA approval for treatment-resistant schizophrenia cases following failure with antipsyhotics from two separate groups with sufficient doses for at least six weeks duration and also preventing suicidal behavior in patients with schizophrenia and schizoaffective disorder. While at least 30% of schizophrenia patients are treatment- resistant and suicide rate is 5%; clozapine, both in Turkey and around the world, is used 10–15 times less in 2–10% of patients. This is not easy to explain rationally like in phobias. Although this cannot be exactly labeled as phobia or clozaphobia, labeling it as a clozaphobic attitude might be appropriate. In our opinion, claiming that prescription of clozapine less than required by the psychiatrists in Turkey due to this clozaphobic attitude is an important public health problem would not be an exaggeration. In addition to clozaphobic attitude, one of the major reasons underlying this attitude is clinicians’ lack of adequate awareness and experience in managing the potential serious adverse events. Clozapine causes major adverse events such as agranulocytosis, myocarditis/ cardiomyopathy, and epileptic seizures along with side effects such as weight gain, constipation, metabolic syndrome which might compromise patient’s health. In addition, daytime sedation, urinary incontinence at night, and hipersalivation can adveresly affect the quality of life of patients. Blood count monitoring for 18 weeks is another reason for reluctant use of clozapine. All these side effects and challenges can be overcome with specific approaches. The FDA promoted a rational use of clozapine with REMS (Risk Evaluation and Mitigation Strategy) program. In this review, updated information about clozapine have been outlined and clinicians were aimed to be informed by the pharmacoeconomics advantages of clozapine and how to overcome the potential adverse events in clozapine use.