Prescribing practices of clozapine in India: Results of a opinion survey of psychiatrists

Abstract

Byline: Amresh. Shrivastava, Nilesh. Shah Sir, Clozapine has emerged as a gold standard for treatment resistant schizophrenia. It is also effective in a variety of clinical conditions. It is additionally approved for suicide in schizophrenia. However practice of clozapine therapy is complex due to its side effect profile, need for regular blood monitoring, continued clinical monitoring and requirements of logistical support system for the same. Indian conditions are diverse not only socio-economically but also in pattern of prescribing. Practice of psychiatry in India is therefore challenging. Internationally clozapine is a centrally monitored and guided therapy involving a number of agencies. The present report attempts to examine prescribing and monitoring practices of clozapine in Indian context. Clozapine is an atypical antipsychotic, which is credited to have the distinction of bringing in the second revolution in psychopharmacology. It has been main focus of management for treatment-resistant schizophrenia. It has also provided a probe for the biological mechanism of schizophrenia. Many patients became functional with clozapine therapy and have returned to college and work.[sup] [1] After several deaths due to agranulocytosis, the drug was approved with a condition of stringent blood monitoring, and this practice is strictly adhered to in each and every western countries. Clinical practice in India does not have the benefit of a centralized blood monitoring system. The present study is aimed to explore the prescribing practice of clozapine in this context. Serum level monitoring is also not available in routine clinical practice. These constrains may change the practice of clozapine therapy.[sup] [2],[3] The study was done using a specifically prepared semi- structured performa containing 32 items and the questionnaire circulated to about 500 psychiatrists in India. A sizable number of posting was done in urban areas besides metro cities and the survey was voluntary. The responses received were analyzed. A total of 117 responses were received in this study, 9.4% of the psychiatrists have reported using clozapine even before it was launched in Indian Market. Antipsychotic prescribing practices are influenced by several factors. Chong et al. noted that Japan had a high frequency of prescribing high doses and polypharmacy; Singapore had a high utilization of depot injections, while China had a higher prescription of clozapine. First-generation drugs were mainly for controlling aggressive behavior, while second-generation drugs were targeted at the alleviation of positive, negative psychotic symptoms as well as disruptive behavior in schizophrenia. The pattern of antipsychotic medication use varies in different countries and is likely to be influenced by the prevailing health-care system, the availability and cost of the drugs.[sup] [4] Most of the psychiatrists using clozapine have an experience of more than 10 years (51%, between 10 and 20 yrs; 28%> 20 years). In the present study, 50% doctors have been using clozapine because they had one more option, and only 28% doctors felt that the knowledge of efficacy has guided their clinical decision.[sup] [5] Further, 43% doctors felt that clozapine provides very good and excellent outcome. The majority opinion was that clozapine provided an efficacy from 40 to 70% in terms of symptom reduction. Switching to clozapine is recommended under strict monitoring with a definite washout period either on outpatient or on inpatient basis.[sup] [6] However, in this study, only 39% preferred stopping ongoing antipsychotic before starting clozapine. A majority of them used the gradual introduction method, 41% preferred to start clozapine gradually, while gradually withdrawing the existing antipsychotic. Eighty-four percent preferred to maintain patients on single drug clozapine as per best practices norm. …