Questions for pharmacist providers in clozapine clinics: Boerth

Abstract

I've been operating the clozapine clinic at our Medical Center for over 7 years now. The clinic already existed before I was hired. I was given the option of running the clinic, and since it was the first clinic opportunity presented to me, I gladly accepted.I've been working as a pharmacist in mental health for over 10 years. I completed a 1-year residency in psychiatric pharmacy practice at the Institute of Living/Hartford Hospital in affiliation with the University of Connecticut School of Pharmacy, and remained there for one additional year as a psychiatric pharmacy fellow. During my time there, I was very grateful and fortunate to have outstanding mentorship from Dr. Charles Caley. I then pursued a clinical specialist position in psychiatric pharmacy at the VA San Diego Healthcare System, where I had the good fortune of continuing to expand my clinical endeavors under the direction of Dr. Jonathan Lacro.I maintain a timely monitoring schedule for metabolic issues, and ensure my patients have primary care coordinated. We have an electronic mental health 'dashboard' that we use at the VA, which can help us track our goals with monitoring parameter compliance rates, along with health targets for lipids, blood pressure, weight, and A1C. I think this sets the bar high for standards of care in a mental health clinic.There's a fair amount of variety to my days. On any given day I could be involved in my general adult psychiatry clinic, clozapine clinic, on inpatient psychiatry rounding with a multidisciplinary team, consulting with psychiatry residents in our psychiatry primary care clinic, or training pharmacy students and residents. There is also a modest staffing component to my week.I currently have two half-days devoted to clozapine clinics, one at our Medical Center in La Jolla and the other at one of our community-based outpatient clinics. I conduct all of the patient assessments, laboratory monitoring, and medication therapy management in the clinic. Once a patient has been assessed and the pertinent labwork has been reviewed, a clozapine prescription is entered on behalf of the supervisory attending psychiatrist (as pharmacists currently do not have the ability to prescribe clozapine). We also track about a half dozen clozapine patients living in long-term locked placement settings, so I devote additional time each week to ensuring that the nursing homes are reporting the necessary lab data to me in order for us to procure clozapine prescription renewals.Yes, we are recognized as providers, and use billing codes for our face-to-face patient encounters.I get a great deal of satisfaction when I see robust clozapine responses in cases that were completely unresponsive to the usual therapies. The turnaround stories in patient functioning are occasionally quite dramatic.I have been providing some peripheral support and expertise to the academic detailing section of our pharmacy service, as they have been working on a broad-based project to expand clozapine access and utilization at the VA. Outside of this, my recent interest has been to examine a consulting pharmacist's impact on lipid goals in mental health patients enrolled in a dual psychiatry primary care clinic setting.I would first suggest that a pharmacist establish a strong working relationship with an attending psychiatrist, if they haven't already done so. Interested pharmacists should also gain familiarity with clozapine policies and registration requirements both at their own medical facility (here at the VA, we have our own national guideline that we follow) and at the drug manufacturer level. Then, work towards establishing a scope of practice that both the psychiatrist and pharmacist can agree upon.We definitely require that all of our pharmacy students and residents gain exposure to the clozapine clinic during their psychiatric pharmacy rotations. They are expected to get comfortable with conducting mental status exams, interpretation of laboratory results, assessments of treatment responses & side effects, discussing modifications to treatment plans, and documenting findings in progress notes. One of the unique benefits of the clozapine clinic is that the frequency with which patients must return to clinic provides a longitudinal teaching opportunity for our trainees.The clozapine package labeling would be a very useful place to start. Also, the landmark clozapine trial conducted by Kane and colleagues (Arch Gen Psychiatry. 1988;45(9):789–796) would be worthy of literature review. Extensive clozapine resources and registration guidance can also be found at: clozaril.com (maintained by Novartis, the makers of brand Clozaril®), or additional clozapine websites maintained by a variety of other generic manufacturers of clozapine.