Clozapine would be an effective choice for Caitlyn since this medication is prescribed for individuals suffering from severe forms of schizophrenia who do not respond to standard antipsychotic drug treatment for a long time (Novartis, n.d.).
Apart from resistance to other antipsychotic medicines, clozapine is prescribed when the patient demonstrates self-injurious or suicidal conduct (Freudenreich & McEvoy, 2018). Since clozapine has several severe side effects, it can only be considered under the circumstances when benefits for the patient’s mental health will not cause disadvantages in physical health dimensions, such as neutropenia, cardiac disease, or seizures (Freudenreich & McEvoy, 2018).
Before initializing clozapine treatment, it is crucial to complete several tests. Since neutropenia is one of the possible side effects, it is necessary to perform the baseline white blood cell (WBC) count (Novartis, n.d.). As a part of WBC, absolute neutrophil count (ANC) should be checked. The US Food and Drug Administration (FDA) set the requirement of a minimum ANC as 1500/microL (Freudenreich & McEvoy, 2018).
If the count is lower, the initiation of clozapine is not allowed. Apart from that, such measurements as body mass index, fasting lipids, and fasting blood sugar should be made. Since Caitlyn is of childbearing age, a pregnancy test needs to be taken (Freudenreich & McEvoy, 2018). Also, the patient’s vital signs, electrocardiogram, and drug levels have to be checked. All of these tests are vital since even a slight deviation from norms within any of the measures can lead to severe negative outcomes for Caitlyn.
It is recommended to start treatment with clozapine with 12.5mg (half of a 25-mg tablet) one-two times a day. If the patient responds well, the dose may be increased to 25-50mg daily (Novartis, n.d.). By the end of the first fortnight of treatment, in the conditions of appropriate toleration, the dose may reach 300-450mg daily. Further increments of the drug dose should not exceed 100mg per week (Novartis, n.d.). Upon stabilizing the dose, all or most of it may be administered at bedtime. By doing so, a sedative effect will be reached, which is good for sleep (Freudenreich & McEvoy, 2018). At the same time, such an administration will help to avoid daytime sedation.
The prescriber website for specialists prescribing clozapine is https://www.clozapinerems.com/. Each prescriber is required to register and become a participant of the Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program. The program helps to avoid fatal infections by making sure that requirements for prescription, dispensation, and reception of the drug are followed (“What is the Clozapine REMS Program?” 2019). The REMS program helps prescribers to manage risks defined by the FDA.
For patients taking clozapine, ongoing monitoring is strongly recommended. Frequent blood cell counts are needed to eliminate the risk of agranulocytosis (Winkler et al., 2014). At the initial stage of treatment, if WBC is ≥3500/mm3, and ANC is ≥2000/mm3, they should be monitored every week for six months (Novartis, n.d.). During the next six months, monitoring takes place every two weeks. In the case of a substantial drop in WBC or ANC, or if mild or moderate granulocytopenia develops, increased monitoring or interruption of therapy is recommended (Novartis, n.d.). In the case of severe leukopenia, treatment should be discontinued.
The rationale for such monitoring is the reduction of the patient’s risk of developing severe side effects. These include neutropenia, severe orthostasis, and myocarditis (Sarpal, Gannon, & Chengappa, 2019). Other potential adverse outcomes are pulmonary embolism, seizures, weight gain, excessive salivation, constipation, urinary incontinence, sedation, and movement disorders (Freudenreich & McEvoy, 2018).
Freudenreich, O., & McEvoy, J. (2018). Guidelines for prescribing clozapine in schizophrenia. Web.
Novartis. (n.d.). Clozaril (clozapine) tablets. Web.
Sarpal, D. K., Gannon, J., & Chengappa, K. N. R. (2019). Thirty years of clozapine treatment: Successes, challenges, and future directions. UPMC Western Psychiatric Hospital. Web.
What is the Clozapine REMS Program? (n.d.). Web.
Winkler, T. E., Ben-Yoav, H., Chocron, S. E., Kim, E., Kelly, D. L., Payne, G. F., & Ghodssi, R. (2014). Electrochemical study of the catechol-modified chitosan system for clozapine treatment monitoring. Langmuir, 30(48), 14686-14693.