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Clozapine, References, Sealock, K., Lilley, L. L., Snyder, J. S., Collins,…
Clozapine
Drug Interactions
Increased anticholinergic effects when combined with other anticholinergic agents like antihystamines
Usage with SSRIs can increase serum levels and risk of toxicity
Increased risk of CNS depression when taken with other depressants
Increased risk of hypotension when taken with alcohol, nitrates, or antihypertensives
Contraindicated with Lithium due to increased risk of CNS reactions
Risk of bone marrow depression with antihypertensive or radiation therapy
Phenytoin, nicotine, or rifampin can decrease clozapine levels leading to decreased efficacy
Drug Information
Contraindications: known drug intolerance, myeloproliferative disorders, severe granulocytopenia, CNS depression or come, narrow-angle glaucoma, bone marrow depression, or uncontrolled epilepsy
Pharmacokinetics
Absorption: absorbed well via oral route
Distribution: rapid distribution through body, able to cross blood-brain barrier and placenta
Metabolism: metabolized via first pass effect in liver
Excretion: primarily excreted after metabolism via urine and feces, half life of 8-12 hours
Mechanism of action: blocks dopaminergic receptors in mesolimbic area of the brain. Has some anticholinergic and alpha-adrenergic blocking properties
Results in the reduction of psychotic symptoms and depressive thoughts
Adverse effects
Common: dizziness, sedation, hypotension, tachycardia, constipation
Severe: neuroleptic malignant syndrome, seizures, myocarditis, AGRANULOCYTOSIS, leukopenia
Agranulocytosis is of particular concern for clients taking Clozapine, requires regular CBC counts throughout and for up to 4 weeks after administration
Notably, clozapine causes minor to no extrapyramidal effects unlike many antipsychotics making it ideal for Parkinson's patients who need antipsychotic medication
Indications: Treatment resistant schizophrenia, psychotic patients with Parkinson's
Trade names: Clozaril, FazaClo
Nursing Implications
Assessment
Perform a full head to toe assessment upon admission, obtain information from client, guardian, and medical records regarding known drug intolerances, perform MSE to determine mental status and presence of psychotic symptoms, determine effectiveness of past antipsychotics to ensure clozapine is indicated, obtain a CBC count, check medical records for history of epilepsy
Implementation
dosage begins small and is increased gradually over time with clients taking 1-2 pills daily, monitor client's mental status before and after drug administration, take client's BP before and frequently during therapy, assess BMI and weight throughout therapy as clozapine can cause weight gain, make sure client is actually taking medication and not cheeking, administer with milk or food to reduce chance of gastric irritation
Evaluation
Perform MSEs to monitor client for continued signs of psychotic symptoms and or depressive symptoms
Perform weekly WBCs to monitor for risk of agranulocytosis
Monitor client for potential signs of myocarditis
Monitor for signs of akathisia or extrapyramidal effects
Monitor for seizure warning due to lowering or seizure threshold
Monitor for signs of neuroleptic malignant syndrome
Teachings
Instruct client on the importance of taking medication regularly as directed
Explain to client reasoning for WBC count monitoring
Make sure client knows what extrapyramidal symptoms are (may have previous knowledge from prior meds) and to notify someone immediately if they notice them
Clients are told that nicotine can reduce the effects of clozapine
Let client know about the risks of orthostatic hypotension and to change positions slowly
Medication may cause seizures or drowsiness
Warn client about the dangers of severe CNS depression when taken with other CNS depressants
Describe symptoms of neuroleptic malignant syndrome to client and to report the signs and symptoms immediately
Let client know they will need continual checks in with their healthcare provider while taking clozapine
Case Study
Client P.T. is a 36 year old female who was diagnosed with schizophrenia in her early 20s. Since then P.T. has tried many different medications but all have proven unsuccessful in managing her schizophrenia symptoms. Client normally lives with her adult parents and has had trouble holding down a job due to acute exacerbations of her symptoms. Client has been admitted to the stabilization psychiatric unit after being certified under the mental health act and her psychiatrist has decided to start her on clozapine as a "last resort" medication to attempt to manage her symptoms.
References
Sealock, K., Lilley, L. L., Snyder, J. S., Collins, S. R., & Seneviratne, C. (2021).
Lilley's pharmacology for Canadian health care practice
. Elsevier.
Vallerand, A. H., & Sanoski, C. A. (2021). Davis's drug guide for nurses. F.A. Davis Company.