Understanding Clozapine: Dr Syl Explains WHAT YOU NEED TO KNOW
Summary
TLDRThis video delves into the complex nature of clozapine, an antipsychotic medication, highlighting its efficacy in treating treatment-resistant schizophrenia. It discusses the drug's history, including a period of market withdrawal due to severe side effects like agranulocytosis. The speaker outlines the drug's indications, its pharmacological mechanisms, and the critical side effects, emphasizing the importance of stringent monitoring. Despite the potential for serious side effects like neutropenia and myocarditis, clozapine's effectiveness in reducing psychosis, aggression, and suicidal tendencies is underscored, with a call for balanced risk assessment and patient autonomy in treatment decisions.
Takeaways
- 💊 Clozapine is a highly effective antipsychotic medication, particularly for treatment-resistant schizophrenia.
- ⚠️ Clozapine carries significant side effects, including rare but serious conditions like neutropenia and agranulocytosis, necessitating strict monitoring.
- 📈 The drug was withdrawn from the market due to deaths from agranulocytosis but was reintroduced with stringent monitoring protocols.
- 🏥 Initiation of clozapine typically occurs in a hospital setting to allow for gradual dose escalation and intensive monitoring.
- 🧪 Regular blood tests are essential for early detection of potentially life-threatening side effects, with the frequency of testing easing after 18 weeks.
- 🌐 The use of clozapine varies widely across countries, with some having more stringent monitoring requirements than others.
- 🧠 Clozapine's mechanism of action is not fully understood, but it is known to bind to various neurotransmitter receptors, including dopamine and serotonin.
- 🤔 The drug is also indicated for treatment-resistant mania, suicidality, and aggressive behavior, as well as certain conditions like autism spectrum disorder.
- 💤 Common side effects of clozapine include hypersalivation, sedation, and significant weight gain, which require management strategies.
- 🏋️♂️ Patients on clozapine must adopt a healthy lifestyle with regular exercise and a balanced diet to counteract weight gain and other metabolic effects.
Q & A
What is the primary focus of the video script?
-The primary focus of the video script is to discuss Clozapine, an antipsychotic medication, covering its benefits, side effects, history, indications for use, pharmacology, and the monitoring requirements associated with its use.
What is the significance of the patient story involving Mr. AB?
-The patient story involving Mr. AB is significant as it illustrates a real-life example of how Clozapine can be effectively used in treating treatment-resistant schizophrenia, highlighting its positive impact on patients who do not respond well to other antipsychotic medications.
Why was Clozapine temporarily taken off the market?
-Clozapine was temporarily taken off the market due to cases of agranulocytosis, a condition where white blood cell count drops significantly, leading to immunocompromise and, in severe cases, death from infections.
What are the indications for using Clozapine according to the script?
-According to the script, Clozapine is indicated for treatment-resistant schizophrenia, treatment-resistant mania, reducing suicidal tendencies in psychotic illnesses, and in some cases, for aggressive behaviors and psychotic depression.
How does Clozapine work, and why is its mechanism of action considered complex?
-Clozapine works by binding to various receptors, including dopamine (D1, D4), serotonin, and others, with a unique 'hit and run' mechanism. Its mechanism is considered complex because it does not strongly bind to the D2 receptor, which is typically associated with reducing psychosis, and it also has immunomodulatory properties, affecting the immune system response in the brain.
What are the rare but serious side effects of Clozapine that require stringent monitoring?
-The rare but serious side effects of Clozapine that require stringent monitoring are neutropenia and agranulocytosis, which involve a decrease in neutrophil count, potentially leading to life-threatening infections, and myocarditis, which is inflammation of the heart muscles.
Why is it important to monitor for fever while on Clozapine?
-Monitoring for fever while on Clozapine is important because fever can be an early sign of myocarditis or neutropenia, both of which are serious side effects. Early detection through regular blood tests and medical review can prevent severe complications.
What are some common side effects of Clozapine mentioned in the script?
-Common side effects of Clozapine mentioned in the script include hypersalivation, sedation, and weight gain. These side effects can impact patient compliance and quality of life, requiring management strategies such as medication adjustments or lifestyle changes.
How often are blood tests required when starting Clozapine, and why?
-When starting Clozapine, blood tests are required weekly for 18 weeks to closely monitor for the rare but serious side effects like neutropenia and myocarditis. After 18 weeks, the frequency of blood tests can be reduced to monthly because the risk of these side effects significantly decreases.
What is the significance of the monitoring protocol for Clozapine, and why is compliance crucial?
-The monitoring protocol for Clozapine is significant because it helps to identify and manage serious side effects early, ensuring patient safety. Compliance is crucial because missing doses or failing to follow the monitoring schedule can lead to a loss of the medication's benefits and an increased risk of side effects. Missing Clozapine for 72 hours requires restarting the entire monitoring process.
Outlines
💊 Introduction to Clozapine's Dual Nature
The paragraph introduces the topic of Clozapine, an antipsychotic medication, highlighting its effectiveness for treatment-resistant schizophrenia but also foreshadowing its complex side effects. The speaker outlines the video's structure, which includes a patient story, historical context, indications for use, pharmacology, and a detailed discussion on side effects and monitoring requirements. The speaker aims to make the content accessible to a broad audience, including non-medical professionals.
📚 Historical Overview and Effectiveness of Clozapine
This section delves into the history of Clozapine, from its discovery in the 1950s to its temporary withdrawal from the market due to agranulocytosis, a severe side effect. The speaker discusses the reintroduction of Clozapine in the 1990s with strict monitoring requirements and emphasizes its high efficacy, particularly in treatment-resistant schizophrenia. The paragraph also touches on the variability in Clozapine usage across different countries.
🧬 Pharmacological Insights and Indications
The speaker explores the pharmacology of Clozapine, explaining its receptor binding profile and its unique 'hit and run' mechanism. Clozapine's broader binding to various receptors is suggested as a reason for its reduced extrapyramidal symptoms compared to other antipsychotics. The paragraph outlines Clozapine's indications, including treatment-resistant schizophrenia, mania, suicidality, aggression, and certain conditions like autism spectrum disorder and psychotic depression.
⚠️ Navigating Clozapine's Side Effects
A detailed examination of Clozapine's side effects is presented, distinguishing between common and rare but serious effects. Neutropenia and agranulocytosis are highlighted as rare yet critical side effects, with an explanation of their mechanisms involving the clozapine molecule's interaction with neutrophils. The paragraph also mentions myocarditis as another serious side effect, emphasizing the importance of regular blood tests and medical monitoring.
🩺 Monitoring and Management Strategies
The paragraph discusses the rigorous monitoring process required for patients on Clozapine, including initial blood tests, ECGs, and echocardiograms. The speaker outlines the frequency of blood tests, which are weekly for the first 18 weeks and then monthly, and the importance of compliance to avoid restarting the monitoring process. The paragraph also addresses common side effects like hypersalivation, sedation, and weight gain, offering practical advice for management.
🌟 Conclusion on Clozapine's Utility and Caution
In conclusion, the speaker reiterates Clozapine's effectiveness for patients unresponsive to other antipsychotics, advocating for its use while emphasizing the importance of adherence to the medication regimen. The speaker encourages viewers to consult with healthcare professionals before starting Clozapine and to maintain open communication with their medical team to manage potential side effects effectively.
Mindmap
Keywords
💡Clozapine
💡Neutropenia
💡Agranulocytosis
💡Pharmacology
💡Schizophrenia
💡Myocarditis
💡Hypersalivation
💡Sedation
💡Weight Gain
💡Extrapyramidal Symptoms (EPS)
Highlights
Clozapine is an effective drug for treatment-resistant schizophrenia.
The video discusses the complex nature of clozapine, including its history and side effects.
Clozapine was taken off the market due to agranulocytosis-related deaths but was reintroduced with strict monitoring.
Mr. AB's patient story illustrates the effectiveness of clozapine in treating resistant psychosis.
Clozapine's use is indicated for treatment-resistant schizophrenia, mania, and suicidal behaviors.
The pharmacology of clozapine is not fully understood, but it is known to bind to various receptors.
Clozapine reduces positive symptoms of psychosis, such as hallucinations and delusions.
It also helps with negative symptoms like lack of motivation and emotional blunting.
Clozapine has anti-aggressive and anti-suicidal properties, making it valuable for certain patient populations.
The side effects of clozapine include common issues like hypersalivation and sedation.
Rare but serious side effects include neutropenia and myocarditis, requiring intensive monitoring.
Weight gain is a common side effect of clozapine, necessitating a commitment to a healthy lifestyle.
Starting clozapine involves a gradual dose increase and intensive monitoring, often as an inpatient.
Compliance with clozapine is crucial; missing doses can require restarting the monitoring process.
The video concludes that clozapine is a life-changing medicine for those unresponsive to other treatments.
The presenter emphasizes the importance of discussing clozapine with a doctor before starting treatment.
Transcripts
so yes I've been telling you how good
cause of pain is but now it's time to
tell you uh the not so good side of
clozapine in this video we're going to
talk about all things clozapine an
incredible drug with some side effects
we need to know about very complex drug
uh so let's get into it so the outline
of this video will have five parts the
first is a bit of a patient story to
give you an example of how you commonly
see clonazepine being used the second is
we'll talk just a touch about the
history of cause of pain because it's
pretty interesting uh given the fact
that it was actually taken off the
market at one point uh we'll talk about
the indications for its use the
chemistry and the pharmacology around
how it works or at least how we think it
works you know there's still a lot to be
discovered about the human brain and
finally the most important thing for
patients and people who are educating
people around clozapine the most
important thing to know is the side
effects and the monitoring requirements
for those side effects a quick note this
will probably be a level of maybe a
junior maybe a senior medical student
Junior doctor but I will try and make it
useful for everyone even if you're not
in the medical field or not a medical
professional so with that being said
let's get into it
so let's start with a bit of a patient
story
um this is kind of made up an
amalgamation of different patients I've
seen uh over the years uh they kind of
give an example of how good cause of
pain is so let's just call this guy Mr a
b uh he's 40
um and he has a diagnosis of
schizophrenia when he was 20 years old
when he was 20 he was found wandering a
skate park at 2AM in the morning
completely disorganized this is after
months and months of socially being
withdrawn from his family and friends uh
and police picked him up and he just
made no sense when he was speaking which
is what we call loosening of
associations it's an example of
disordered thought form which is a sign
of psychosis and he was diagnosed with
his first episode psychosis since then
he had tried after that lanzapine or
piprazole combinations of antipsychotics
and nothing really worked for him he
kept coming back to hospital with
disorganized thought and uh and saying
things that didn't make sense and and
and sometimes you know behaving
dangerously like punching walls or
running on the streets in the middle of
the night and into traffic so it can be
really dangerous being psychotic
obviously so finally he goes into
hospital and they start him on clozapine
because it one of the indications which
we will go through is treatment
resistance schizophrenia and because he
had recurrent psychosis he had accrued
the diagnosis of schizophrenia but once
he started Clozapine he hadn't he ever
since he started Cosby and he hadn't
gone back to hospital ever since it
worked really really well it's the best
he's ever been then six years later he
developed something called neutropenia
which is one of the side effects we're
going to talk about and how to stop
cause of pain all right let's stop the
patient's story there and talk about
clozapine so over the past week I had to
give a presentation and I had to go
through a lot of different papers to
talk about uh clozapine but part of it
is I learned a bit about the history
which was very interesting it was
discovered by Wonder Pharmaceuticals in
the 50s and it was kind of brought into
the market 60s and 70s and it was
working really really well but then they
kind of noticed people dying from
something called a granulocytosis which
is essentially when a specific type of
white blood cell so it was a little bit
of a memory jogger your blood is got
water proteins fats and cells in it and
it's got red blood cells and white blood
cells red blood cells do the oxygen
white blood cells do the the immune
system defense there are a lot of
different types of white blood cells but
they can be kind of grouped into the
agranulocytes and the granulocytes and
and the differentiation is actually
completely based off microscopy and how
they look under a microscope not based
on function but the granulocytes are the
things that look like they have granules
like stones or dots under a microscope
and one of those there's like three or
four granulocytes but one of them is the
neutrophil and this is the cell that
gets affected by clozapine in a very
small percentage of people you know less
than one percent uh and uh unfortunately
in Finland they they found nine people
who died because they lacked this white
blood cell and obviously if you don't
have that white blood cell you're
immunocompromised right it's an immune
cell so if you don't have it you're
immunocompromised and these people were
dying from infections so the whole
entire world except for like poor
countries that like didn't really uh
have strict monitoring requirements so
develop open countries such as India
were kept using close pain but most of
the entire world pulled closet paint off
of the market because of the risks and
then they had no clozapine for a decade
and everyone was pretty unwell there was
so many people that just were not
responding to any other psychotics and
so in the 90s there was a couple of
studies that just showed how effective
uh cozipine is over the Alternatives
like chlorpromazine there's a big study
by Canada and uh and so it was
reintroduced but you had to do very
strict monitoring so that you wouldn't
get the agranulocytosis it was to kind
of pick up on agranulocytosis before you
got the symptoms of an infection and
then you would become really unwell so
with the monitoring it reduced the
incidence and the death rate or the
morbidity the the you know the illness
rate of getting sick with
agranulocytosis substantially and ever
since it's been a wonderful drug there's
so much variability in the world like
there are some countries that are so
I mean I gotta say it they're scared of
using it unfairly uh so uh you know the
percentage of people who have
schizophrenia who are on clozapine
ranges from like four percent in the
United States to like 40 in other
countries like Australia so that's a bit
about the history now let's talk a bit
about the indication why would people
ever need to use clozapine well
um the kind of agreed upon International
indication because there are differences
in different countries for when they use
clozapine but the one thing that all
countries agree upon is that it's useful
in treatment resistant schizophrenia
okay so it's when you have a psychotic
chronic psychotic illness that isn't
responding to the other antipsychotics
and just to give you an example of how
effective it is I just will quote this
paper despite non-response to other
antipsychotics the chance of responding
to clozapine is more than 60 percent so
that is saying that if you have failed
two other antipsychotics with a chronic
psychotic illness you have a two out of
three chance of having some response
with clozapine and you know half of
those will have a substantially positive
response so it's a very freaking
effective medicine now there are other
indications for clozapine um you know
and it's always treatment resistant so
treatment resistant Mania you can use
clozapine it's useful for people who are
very suicidal with their illness because
it's got evidence to suggest that it
reduces suicide especially in psychotic
illness it also reduces violence so
people who are very violent uh and
behaviorally aggressive so for example
it's in some countries it's actually
indicated for autism spectrum disorder
for people who suffer from autism who
are just so unwell that they get violent
and then the final indication as well
which kind of falls under psychosis
slash mood a psychotic depression so
people who are so depressed that they've
actually developed a psychosis now in
terms of how it works the pharmacology
now don't click away if you don't
understand any of this stuff because if
you're a patient or okay Giver you need
to listen to the next part which is the
monitoring and the side effects but in
terms of how it works look it's
incompletely understood we know which
receptors it binds to which is very
interesting but it's kind of unexpected
that it works as well as it does based
on those receptors because what we
expect is if people are really psychotic
that when you block a receptor called
the D2 receptor it reduces The psychosis
but what we see with clozapine is that
it actually doesn't bind that strongly
to that receptor it it seems to do this
other thing though it seems to bind on
and off like a hit and run mechanism
where it binds and like it binds and
releases binds and releases really
really quickly so that might be how it
has its effect
um but the the it binds stronger to the
D1 the D4 receptors and and not even
only on the D receptors which stand for
dopamine receptors but it also blocks
serotonin receptors which is the
thinking around why it has less movement
side effects because in case you didn't
know there's other antipsychotics that
have movement side effects they're
called extrapyramidal symptoms
and for the medical students watching it
you've got to know these it's the tart
of dyskinesia parkinsonism with the
hypertonia and the cogwheeling where
they feel stiff as a board the dystonia
uh you know when the with the muscle
spasm and the akathesia the need to move
the inner restlessness so those are the
kind of common
symptoms that you don't get with
clozapine that you might get with other
antipsychotics and it also binds to a
bunch a bunch of other receptors so name
your neurotransmitter it can probably
bind to that receptor so it has
glutaminergic activity anti-cholinergic
activity but also some cholinergic
activity it also has nmda receptor
properties and one thing I don't really
understand in much depth is it has
immunomoduly modularity properties so it
actually affects your immune system
response in the brain that's a bit
Beyond me but the point is we don't
fully understand how it works we just
know it works really really well the key
things it does that works well is it
reduces psychotic positive symptoms so
things like auditory hallucinations
hearing voices hearing mumbling hearing
command hallucinations telling you to do
things it reduces delusions so people
having fixed and false beliefs like
they're being followed like someone's
gonna kill them in the next minute like
they're being or like they've got uh you
know chips implanted in their heads and
they're monitoring their thoughts and
things like that it also works pretty
well for the negative symptoms which a
lot of other antipsychotics don't do
like don't really uh touch on because
they're really hard to treat negative
symptoms if you haven't heard of
negative symptoms these are the symptoms
of psychosis where there's an absence of
of things absence of motivation absence
of thought so literally they'll just
have empty thought times and people can
just sit and lie in bed all day these
are some of the negative symptoms you
see so causing help a little bit with
that and other than the antipsychotic
elements of it it's anti-aggressive and
anti-suicidal all right aggressions kind
of angered towards the outside and
society and suicidal behaviors kind of
anger towards the inside so it reduces
suicide in people who have treatment
resistant schizophrenia and treatment
resistant depression and all those
things I mentioned before but it comes
at a price and so yes I've been telling
you how good cause of pain is but now
it's time to tell you uh the not so good
side of cause of pain positan has side
effects yes because it's so effective it
comes with side effects and they can be
split into two categories the the common
ones and the really rare ones but the
really rare ones can be life-threatening
if they're not picked up on early and
that is why there is very stringent
intensive monitoring when you start
clozapine at the end of the video we'll
talk about what it's like to start cause
of pain but for now I'm just going to
talk through all of the different uh
side effects that you need to know and
so the most famous One rare as it is but
life-threatening if it occurs is
neutropenia and agranulocytosis those
two words are kind of on a spectrum and
what it means is the neutrophil count
goes down now why does it happen
I I think I'm just gonna geek out right
now and go full science here so so you
don't need to understand this but I only
learned about this uh this week and it
and I a lot of other doctors don't know
about this so it's really cool let's
let's do the science so if you actually
look at this screen on Wikipedia you can
um see the clozapine molecule here now
how does this is the clozapine molecule
how does cosmen get metabolized the
medical students you should know this
it's the
sip1a2 enzyme in hepatocytes so it's in
the liver the liver metabolizes
clozapine and what does sip1a2 do it
demethylates it removes a methyl group
CH4 so this is just two ways that it's
um you know this this is the same cause
I've been structure just one's an
animation one's a line structure so it
removes this group here okay it removes
these four here that's a carbon and
three hydrogens when that gets removed
there is a moment of time where there's
nothing there except for the electrons
in this Bond right so there's a free
electron pair it's a valence elect it's
a valence electron pair so they have
um they're very reactive and so what
happens is you get a nitranium ion where
you have basically free electrons that
will bind to anything that's around and
the thinking here is that they bind to
proteins or something in neutrophils
that damages the neutrophils and kill
the neutrophils it's either that they're
called cause direct toxicity through
denaturing proteins or something very
important in neutrophils or that they
cause a haptin mediated immune response
so a haptin this is again this is for
the med students what happened is when
the
protein or or you know chemical like
clozapine binds to a antibody and then
it is expressed on the cell surface and
mediates a cell mediated cytotoxic
response type 4 hypersensitivity
reaction ugh what a big dump that was
but the point is these are the two
mechanisms in which we think the
clozapine causes a granulocytosis super
interesting but why some people get it
and other people's don't we don't know
and what like it's only 99 plus percent
of people will never have this okay it's
it's less than one percent and who will
experience this and why is that we don't
know there are people right now in Labs
trying to work out if there's a genetic
element and there's some very hopeful
researchers out there so it might be a
genetic thing and if that if it is then
that's great because there'll be genetic
testing to predict who'll get it uh and
then maybe the monitoring can be less
stringent because we'll talk about that
at the end so this is the thing that uh
is the reason that people need to get so
many frequent blood tests while they
start clozapine but we won't go through
all the monitoring right now let's keep
going in the side effects the next side
effect to know about is myocarditis
which is essentially inflammation of the
heart muscles and I guess the key
takeaway about a key takeaway for
myocarditis if you're a healthcare
professional or not if you're someone
taking closer bed is to know that the
most common symptom is not chest pain
all right let that sit in and this is
why we do our blood tests to pick up
like we do troponins on the blood test
which is a cardiac enzyme which shows us
that if there's any myocarditis
happening
um it indicates if there could be
myocarditis happening just to clarify
but uh yeah uh Knight is common symptoms
is actually just feeling like crap it's
General malaise fever-like symptoms so
if you ever have a fever while you're
starting cause of pain or if you're on
cause pain you need to get an urgent
medical review uh because fevers can
mean it can mean a granulocytosis and an
immunocompromised State getting an
infection or it could mean myocarditis
you're feeling like crap you're feeling
lethargic you're feeling flu-like uh
it's it's really bad to get my God
either so uh so
um that's the that's the other thing we
also do monitoring with the ECG
uh to pick up on this because you can
see changes on the ECG now those are the
two rare side effects that people think
clozapine need to know about but
um let's also talk about the common side
effects that uh kind of really affect
compliance with clozapine and can can
ruin people's lives if they're not you
know on top of them so the first one
that people are usually a little bit
embarrassed about is hyper salivation so
it makes people drool especially at
night when they're going to sleep and
they wake up with pillows that are
drenched so a couple of things there are
ways to reduce this first you can get
specialized pillows they're called
clozapine pillows look them up on Google
or ask your clozapine Clinic if they
have any and they're either waterproofed
or they're like towel like absorbent and
the second thing is you can ask your
doctor for different strategies with
medications so there are atropine drops
or hyacin tablets so not tablets
lozenges that dry up your mouth and so
these help reduce hyper salivation it
doesn't fully eliminate it and the weird
thing is it's not dose dependent it's
not like reducing clozapine makes you
salivate less and it's hard it's
impossible to predict who's gonna get it
because not everyone has hyper
salivation some people are on 900
milligrams of Clozapine with a dry mouth
and others are on 150 milligrams of
Clozapine and it's just you know it's a
it's a bloody Fountain the reason this
happens it's probably a mix of reasons
there's a there's a cholinergic element
to the medicine and there's also a lack
of swallowing that occurs overnight when
you're sleeping so it's probably a mix
of both
all right the next common side effect to
sedation yes uh all antipsychotics can
sedate uh and this is no exception so
um you know the ways to address that is
that is dose responsive so you work with
your doctor to find the optimal dose for
you and the optimal time to take your
dose so if you're taking your dose at
midnight and you're waking up groggy
yeah no wonder like take it early take
it at seven and then usually it's a bit
better by the time you need to get up
it's worth noting though that coffee
doesn't fix this so people have I've met
people smashing 10 coffees in the
morning to try and beat
um the sedation from antipsychotics
caffeine ain't gonna fix the sedation
from antipsychotics guys you've got to
work with your doctors to to find the
right treatment for you and there's
probably a bit of acceptance that needs
like realistically unite except there
will be just some sedation with these
medicines but it's better than being
psychotic
anyway easy for me to say so uh the next
side effect to talk about is
um
the most this is the most common it's
weight gain all right weight gain people
can get fat on clozapine if you're not
really careful when you start on
clozapine you are starting on daily gym
and a healthy diet for the rest of your
life if you aren't ready for that you
need to really think you know you need
to be careful because clozapine will
make you eat more than you should and
and then you grow and you get diabetes
and all the rest of it so
um I hope that one message is clear is
that if you're going to start clozapine
you need to get into the mentality that
you're going to do lots of exercise and
eat like healthy foods you're going to
eat more than you want I don't know how
to prevent that but
but hopefully just choose healthier
foods people just crave greasy food when
they're on antipsychotics I don't know
why not like I've looked into the
research and it's just not really clear
why this happens but but you just gotta
you know you just gotta do lots of
exercise and eat as healthy as you
possibly can because it's it's so common
a really cool thing about clozapine
though is that there is not much epse or
movement side effects and in fact if
people have had tardive dyskinesia where
their mouth and booze involuntarily
because of other medicines that they
take cause of pain is a great
alternative because it actually reduces
tardive dyskinesia all right guys it's
time to talk about the monitoring and if
you've made it till now good on you
because this is the most important part
but also the hardest part to talk about
it's it's really a tough medicine to
start but once you've started it's much
more realistic so usually it started as
an inpatient and you start at very small
doses at like less than a tenth of what
you will end up on you start on so it's
12.5 milligrams then 25 then then 50
then and it builds up slowly
over the days in its neural tablet
obviously
so so it's important they come into an
inpatient so that they can do that slow
increase in medicines but also so that
they can do all the monitoring so in
terms of the monitoring before you start
the medicine you're going to get a full
set of Bloods including
um your your like cholesterol levels but
then all the other Bloods including your
red blood cells your lights your liver
function your kidney function your your
oh yeah uh like iron studies is a good
idea and hematinx like B12 folate uh
they're all good ideas to start off
before you start on clozapine
um I guess it's important to know that
there are different protocols in
different countries so and in different
states so in my state I use something
called the ecpms system which which is
the cause of real companies system and
cause real is a type of clozapine it's
the brand name for one of the clozapines
and
this is that this is the guidelines like
this is two pages per sheet and there's
like uh 30 pages so you know it's like
100 Pages uh and it tells you all the
monitoring that the doctors have to do
it's usually freely available if you if
you email the the um uh the company or
ask your doctor you can probably read it
I wouldn't have any problems with
someone reading this
and uh yeah so all the blood tests you
need to get an ECG where they look at
your heart electrical Pathways you need
to get a
um
echocardiogram where they look at your
heart with an ultrasound and I think
that's about it before starting but then
you need to get blood tests and you need
to get weekly blood tests and this this
is variable across the world
um but in in where we are It's weekly
blood tests for 16 weeks sorry
correction for 18 weeks here and then it
goes to monthly after 18 weeks because
after 18 weeks it's really unlikely that
you get the myocarditis or the
neutropenia which we talked about
earlier and listen this is where you
make the point around compliance this is
where I should talk about compliance
sorry uh if you stop cause of pain for
72 hours three days
you have to restart all of this so if
you've been taking clozapine for months
or years please don't just forget your
dose for three days in a row you know go
to the hospital if you need to they'll
help they'll give you a dose they'll
sort it out because if you miss three
days of clozapine again this depends on
where you are in the world in in
Australia you have to restart the whole
monitoring process again and yes some
people can do it in the community but
most of the time it means you have to go
into hospital to do it as an inpatient
so that they can do all the regular
thorough monitoring and after you finish
that really intense kind of um 18 weeks
of blood tests every week you can go to
monthly and you join What's called the
clozapine Clinic where you see a
clozapine nurse or doctor once a month
for the rest of your life so look you
know it is a intense regime but it is
such an effective medicine that it's
worth the kind of the price you pay in
terms of the monetary in fact people
think that going regularly to see the
nurse doctor keeps the engagement up
which actually keeps people well because
then the nurse or the doctor will pick
up if there's any kind of symptoms now
there are moves uh and right and then
people talking about making the
monitoring of clothes being less
stringent because of how good a medicine
it is and how rare the
um kind of neutrophil neutropenia is uh
it's kind of unfair to kind of require
such intense monitoring for people who
like there's a lot of people who aren't
on clozapine because they can't meet the
monitoring requirements and those people
are being done a disservice because
um because of essentially fear that they
might get neutropenia that's missed but
my view my personal opinion and remember
I'm a I'm a doctor in training I'm not a
psychiatrist and you need to talk to
your psychiatrist about their opinion
before you take any of these medicines
obviously
um but my opinion is it should the risk
should you know we should promote
people's autonomy in assessing risk it
should be up to the patient to accept or
not accept risk with the with monitoring
requirements so if they choose to do
every three months and they understand
that that comes at an increased risk of
getting
um uh you know neutropenia then then we
should you know that's that's an
important thing for the doctors to
appreciate that being said I've seen a
lot of neutropenia I've never seen
anyone die from it because we always
pick it up so early with these regular
blood tests so
um maybe my opinion would change if I
saw someone become really unwell with it
all right guys that is it for this video
um I hope that was uh useful
um my conclusion is that uh clozapine is
an extremely effective medicine for
people who have not responded to other
antipsychotics if I had schizophrenia I
would take clozapine that's what I would
want because of how effective it is and
how it changes people's lives the key
thing is just keep that compliance going
just take the bloody medicine I know
it's not perfect I know there are side
effects I know it sucks but it's better
than the alternative and if you want to
start just talk to your doctor first do
always talk to your bloody doctor first
guys that's my advice
um I wish you all an absolutely
beautiful day and I'll see you in the
next video alright bye for now
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