Mandatory certification for clozapine prescribing

Abstract

The Clozapine Prescription Rates and Current Clinical Practice Clozapine is the only registered treatment for therapy-resistant schizophrenia (meaning, after treatment with two other antipsychotics failed or were not tolerated), psychosis in Parkinson's disease, and, in the United States, for suicidality. Off-label, clozapine is prescribed for therapyresistant disorders, especially therapy-resistant bipolar, borderline personality, violent behavior, or self-harm in patients with psychosis, aggressive behavior, or addiction to cannabis in psychotic disorder and in the animal model. Despite the good evidence of efficacy [1] and now robust evidence that clozapine use may be associated with lowered mortality compared to other antipsychotics [2], the use of clozapine remains suboptimal in most countries, both within and outside Europe [3]. Low prescription rates not only result in poor treatment for schizophrenia, an unintended consequence is that trainees and consultants in psychiatry have less experience and, therefore, lack confidence in initiating and maintaining the clozapine therapy. In a major survey of UK practice, it was found that almost one third of senior consultants have not prescribed the clozapine, for more than a year. It appears that a vicious cycle sets in; because clozapine is less prescribed, doctors have less exposure and confidence in prescribing it which in turn results in even lesser exposure to managing the drug and its side effects. Not surprisingly, this promotes the aura for clozapine as a dangerous drug, which results in prescribers' fear.

Prescription attitudes and practices regarding clozapine among Serbian psychiatrists: results of a nationwide survey

“… 34 , 47 Recently, a mandatory training program for prescribers, which aims to improve the knowledge about clozapine prescription was proposed in order to overcome these issues. 48 …”

“…34,46 Multiple recent studies have shown and confirmed the earlier finding by Tiihonen 34,47 Recently, a mandatory training program for prescribers, which aims to improve the knowledge about clozapine prescription was proposed in order to overcome these issues. 48 Here, we outline our proposed modifications of the national Serbian guidelines. Based on the international literature and the responses we obtained from this survey, we propose three modifications.…”

The ever-growing case for clozapine in the treatment of schizophrenia: an obligation for psychiatrists and psychiatry

“…Clozapine underutilization appears to be attributable particularly to clinician's concerns regarding potential side-effects, especially an overestimation of the risks associated with blood dyscrasia 49*,52,54,55 and a lack of resources for blood sampling and other monitoring procedures 52 . Clinician's apprehension appears to be further amplified by limited knowledge regarding treatment algorithms and side effect management 52,54,56,57 . Importantly, this might result in a vicious cycle of less prescription leading to less expertise 57 .…”

“…Clinician's apprehension appears to be further amplified by limited knowledge regarding treatment algorithms and side effect management 52,54,56,57 . Importantly, this might result in a vicious cycle of less prescription leading to less expertise 57 . Furthermore, psychiatrists predominantly presume that patients would not accept clozapine and its monitoring requirements 53* , regard clozapine treatment as a burden for both patients and prescribers 58,59** , and assume that patients receiving clozapine are less satisfied 60 .…”

Clozapine-induced gastrointestinal hypomotility: presenting features and outcomes, UK pharmacovigilance reports, 1992–2017

“…The mental health pharmacist also has an important role here. The suggestion that education and training in the use of clozapine must become a mandatory requirement of all psychiatry residence and continuing professional development programmes 32 would need to take into account the fact that prevention of CIGH requires a concerted effort from all those involved in the care of the patient, not just the prescribing psychiatrist.…”