Abstract
Clozapine, the choice atypical antipsychotic for refractory schizophrenia, schizoaffective disorder, and bipolar disorder, has been shown to reduce positive and negative symptoms of schizophrenia. Clozapine, though beneficial in reducing the need for hospitalization, rehabilitation, and health care costs, is known as a drug of last resort due to its potential adverse event of clozapine-induced agranulocytosis, which holds a case fatality rate between 4.2 and 16%. Herein, we describe a female patient with longstanding schizoaffective disorder and chronic kidney disease who suffered from clozapine-induced agranulocytosis after failing two other atypical antipsychotics. Retrospective considerations of this case and management highlight risk factors such as HLA status, renal failure, and concurrent valproic acid use which presently do not have official screening, guidelines, or restrictions in place when prescribing clozapine. Additionally, there are no specific clozapine-induced agranulocytosis management recommendations such as G-CSF/filgrastim dose, timing of bone marrow aspirate and biopsy, and use of concomitant valproate. We propose that further comprehensive official screening, monitoring, and guidelines in the prescribing of clozapine, and further guidelines in the treatment of clozapine induced agranulocytosis, could increase the cost-effectiveness of clozapine treatment, and decrease the incidence, and morbidity of this feared adverse event.
Highlights
Clozapine, a dibenzodiazepine antipsychotic exhibiting weak dopaminergic activity and atypical pharmacological properties, is the choice antipsychotic for refractory schizophrenia, schizoaffective disorder, and bipolar disorder [1,2,3,4]
Retrospective considerations of her placement on clozapine and subsequent management of her clozapine-induced agranulocytosis (CIA) brought into question many factors which do not have clear guidelines, including official screening of risk factors which increase likelihood of CIA, as well as clear clinical management for this feared adverse event
This case report provides a spotlight on many factors such as screening for chronic kidney disease (CKD), human leukocyte antigen(HLA) typing, concurrent valproate administration due to potential CYP interactions, and management considerations such as dosing for filgrastim/G-CSF and timing of bone marrow biopsy
Summary
A dibenzodiazepine antipsychotic exhibiting weak dopaminergic activity and atypical pharmacological properties, is the choice antipsychotic for refractory schizophrenia, schizoaffective disorder, and bipolar disorder [1,2,3,4]. Case Reports in Psychiatry describe a patient with longstanding schizoaffective disorder who suffered from CIA after being transitioned to clozapine due to failed trials of risperidone and olanzapine Retrospective considerations of her placement on clozapine and subsequent management of her CIA brought into question many factors which do not have clear guidelines, including official screening of risk factors which increase likelihood of CIA, as well as clear clinical management for this feared adverse event. This case report provides a spotlight on many factors such as screening for chronic kidney disease (CKD), human leukocyte antigen(HLA) typing, concurrent valproate administration due to potential CYP interactions, and management considerations such as dosing for filgrastim/G-CSF and timing of bone marrow biopsy. This analysis aims for further study and future implementation of screening and management guidelines for better informed management of refractory schizophrenia treatment, reduced cases of CIA, and improved management of CIA should it occur
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