Clozapine in the community: Improved access or risky free-for-all?

Winckel, Karl; Siskind, Dan; Hollingworth, Samantha; Robinson, Gail; Mitchell, Scott A.; Varghese, Daniel; Smith, Lesley; Wheeler, Amanda

doi:10.1177/0004867415592957

Cited by 4 publications

(3 citation statements)

References 3 publications

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“…More education is required for community pharmacists on how to manage this information and the clinical relevance of this. This was an issue that had to be addressed in Australia when clozapine dispensing transferred from hospital to community pharmacy for stable patients in 2015 [ 6 ]. A lack of education and inadequate resources were identified as barriers to implementing this service change.…”

Section: Discussionmentioning

confidence: 99%

“…There is evidence in the literature about the communication gap that exists between primary and secondary care services for patients prescribed clozapine [ 5 ]. Obtaining medicines from multiple sources leads to fragmented service delivery, compromises safe use of medicines and, exposes patients to an increased risk of drug-drug interactions (DDIs) and adverse effects [ 5 , 6 ]. There is little published on the consequences of disjointed pharmacy services for those patients who receive clozapine separate to their other medicines.…”

Section: Introductionmentioning

confidence: 99%

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Clozapine Patients at the Interface between Primary and Secondary Care

et al. 2018

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Patients receiving clozapine must undergo routine blood monitoring to screen for neutropenia, and to monitor for potential agranulocytosis. In Cork University Hospital, Cork, Ireland, clozapine is dispensed in the hospital pharmacy and the pharmacists are not aware of co-prescribed medicines, potentially impacting upon patient safety. The aim of this study was to examine the continuity of care of patients prescribed clozapine. A retrospective audit was conducted on patients attending the clozapine clinic at Cork University Hospital and assessed patients’ (i) independent living, (ii) co-prescribed medicines and (iii) knowledge of their community pharmacists regarding co-prescribed clozapine. A list of prescribed medicines for each patient was obtained, and potential drug-drug interactions between these medicines and clozapine were examined using Lexicomp® and Stockley’s Interaction checker. Secondary outcomes included patients’ physical health characteristics, and a review of co-morbidities. Data were collected between the 29 May 2017 and 20 June 2017. Local ethics committee approval was granted. Patients were eligible for inclusion if they were receiving clozapine treatment as part of a registered programme, were aged 18 years or more, and had the capacity to provide written informed consent. Microsoft Excel was used for data analysis. Of 112 patients, (33% female; mean age (SD) 43.9 (11.3) years; 87.5% living independently/in the family home) 86.6% patients reported that they were taking other prescribed medicines from community pharmacies. The mean (SD) number of co-prescribed medicines in addition to clozapine was 4.8 (4) per patient. Two thirds of community pharmacists were unaware of co-prescribed clozapine. Interactions with clozapine were present in all but 3 patients on co-prescribed medicines (n = 97). Lexicomp® reported 2.9 drug-drug interactions/patient and Stockley’s Interaction Checker reported 2.5 drug-drug interactions/patient. Secondary outcomes for patients included BMI, total cholesterol, and HbA1c levels, which were elevated in 75%, 54% and 17% respectively. Patients prescribed clozapine did not receive a seamless service, between primary and secondary care settings. Community pharmacists were not informed of clozapine, prescribed for their patients, in two thirds of cases. Patients in this study were exposed to clozapine-related drug-drug interactions and hence potential adverse effects. This study supports reports in the literature of substandard management of the physical health of this patient group. This study shows that there is an opportunity for pharmacists to develop active roles in the management of all clozapine-related effects, in addition to their traditional obligatory role in haematological monitoring. This study supports the need for a clinical pharmacist to review inpatients commencing on clozapine, monitor for drug-drug interactions and provide counselling.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clozapine Patients at the Interface between Primary and Secondary Care

et al. 2018

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“…21 The possibility of these severe adverse events could also be related to the reported delay in clozapine prescription to patients with appropriate clinical indications -this could be one of the reasons why psychiatrists and pharmacists are reluctant to prescribe and dispense it, respectively, in some hospitals. 22 The main concern related with this phenomenon is that patients who could benefit from the therapeutic effects of clozapine, especially those with TRS, may not receive the appropriate treatment for their illness. In a review by Warnez & Alessi-Severini, the authors estimated that only 25% of patients with TRS were treated with clozapine in 1999.…”

Section: Discussionmentioning

confidence: 99%

Trends in the prescription of clozapine in a psychiatric hospital: a 5-year observational study

Niehues

Balan

Diaz

et al. 2017

Trends Psychiatry Psychother.

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Introduction Clozapine is a well-recognized effective treatment for some patients with treatment-resistant schizophrenia (TRS). Although it has potential benefits and approximately 30% of patients have a clinical indication for clozapine use, prescription rates are low. Objective To evaluate clozapine prescription trends over a 5-year period in a tertiary psychiatric hospital. Methods In this observational study, data prospectively collected by the Medical and Statistical File Service (Serviço de Arquivo Médico e Estatístico) and the Pharmacy Division of Instituto de Psiquiatria de Santa Catarina between January 2010 and December 2014 were summarized and analyzed by investigators blinded to data collection. The number of 100 mg clozapine pills dispensed by the Pharmacy Division to the inpatient units was the outcome and considered a proxy measure of clozapine prescriptions. The number of occupied inpatient unit beds and the number of patients admitted with F20-F29 (ICD-10) diagnoses during the study period were considered to be possible confounders. Results A multiple linear regression model showed that time in months was independently associated with an increase in the number of clozapine pills dispensed by the Pharmacy Division (β coefficient = 15.82; 95% confidence interval 10.88-20.75). Conclusion Clozapine prescriptions were found to have increased during the 5-year period studied, a trend that is opposite to reports from several other countries.

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Community pharmacists’ attitudes and opinions towards supplying clozapine

Gan

O’Reilly

2018

Int J Clin Pharm

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Background Clozapine is very effective for treatment-resistant schizophrenia, but its use has been limited due to the risk of agranulocytosis. From July 2015, clozapine has been accessible from Australian community pharmacies following regulatory changes, but pharmacists' attitudes towards these changes remain unknown. Objective To explore pharmacists' perspectives and experiences in supplying clozapine. Setting Australian community pharmacists. Methods A cross-sectional study with a mixed methods approach involving two phases. An online survey containing Likert-type and open-response questions was distributed to community pharmacists (n = 134) via ClopineCentral™ (clozapine monitoring system). Participants were then invited to participate in semi-structured telephone interviews (n = 12) regarding clozapine supply. Quantitative data were statistically analysed, while qualitative responses were thematically content-analysed. Main outcome measures Pharmacists' responses to surveys and interviews. Results Community pharmacists were supportive towards supplying clozapine as it increased access for consumers. Better patient-pharmacist relationships and holistic care approach were identified to benefit both consumers and pharmacists. Pharmacists reported to be confident (89.6%), have adequate support (73.1%), knowledge (86.6%) and skills (93.3%) in dispensing clozapine. Training and support received facilitated pharmacists' roles, whereas administrative issues, especially in obtaining valid haematology results, posed challenges. Educational and technical improvements were suggested to improve service provision. Conclusion Community pharmacists welcomed the regulatory changes positively and were confident in supporting consumers taking clozapine. Despite challenges present, benefits and facilitators identified supported the feasibility of this service in community pharmacies. Future research should explore other aspects of clozapine supply, such as attitudes of other stakeholders, to improve current supply systems.

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Clozapine in the community: Improved access or risky free-for-all?

Cited by 4 publications

References 3 publications

Clozapine Patients at the Interface between Primary and Secondary Care

Clozapine Patients at the Interface between Primary and Secondary Care

Trends in the prescription of clozapine in a psychiatric hospital: a 5-year observational study

Community pharmacists’ attitudes and opinions towards supplying clozapine

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