Knowledge of Psychiatric Nurses About the Potentially Lethal Side-Effects of Clozapine

Developing evidence-based medication therapy management tools for psychiatric nurses: An evaluative qualitative case study

RATIONALE, AIMS AND OBJECTIVES

Clinical use of psychotropic medications involves diverse risks, addressable by nursing interventions. The research had a dual purpose: developing an "Evidence-Based Medication Therapy Management Guideline" and a "Medication Administration-Tracking Chart" and evaluating their use through an evaluative case study.

METHODS

Evidence-based guideline and chart development and evaluative case study. Initially, Evidence-Based Medication Therapy Management Guideline and Medication Administration Tracking Chart for managing medication in a psychiatric unit were developed. Subsequently, their efficacy was evaluated in a case study involving 10 participating nurses used in the psychiatric unit with 123-bed of a training and research hospital in Turkey. Data was collected through personal forms, interviews, medication charts, and researcher observations, and the analysis employed Merriam's case study method.

RESULTS

Three themes (inception, implementation, termination, and sustainers) and 12 sub-themes emerged. Nurses stated that the research tools filled their information gaps, enhancing the medication therapy management process's effectiveness and safety, improving nursing care quality and continuity, and benefiting patient outcomes. Nurses expressed a desire to consistently use the tools in the unit and provided suggestions.

CONCLUSION

Nurses highlighted the tools' potential to enhance medication safety, psychiatric care, and patient outcomes. However, their stance on using evidence-based tools revealed an approach/avoidance conflict, balancing benefits and barriers. Experience emerged as a hindrance in embracing evidence-based clinical tools. This study is among the first to comprehensively develop evidence-based medication management guideline and administration-tracking chart for psychiatric nurses globally and in our country. Routine use of the tools is expected to enhance nurses' expertise in psychotropic medication management, leading to improved patient outcomes in medication-related aspects.

Constipation in hospitalized psychiatric patients: An underestimated common phenomenon. Retrospective epidemiological study in an adult psychiatric hospital setting

OBJECTIVE

Constipation is more common in patients with mental disorders than in the general population. However, its frequency in hospitalized patients, its association with drugs and how teams become aware of it and take care of it are not fully identified.

METHOD

The retrospective study included 141 male and 127 female new patients admitted for routine treatment at France's largest psychiatric hospital between November 15 and December 11, 2017. A physician reviewed electronic medical records to diagnose constipation and record variables of interest: socio-demographic factors, diagnosis, drugs prescribed and taken. We calculated an anticholinergic impregnation score (AIS) for each patient by using a validated French scale. Patients were then classified into two groups by state of constipation defined by the physician. Univariate and multivariate analyses were used to study the frequency of constipation, factors associated with it and its management.

RESULTS

The prevalence of constipation was 38% (95% CI 32-44). Associated factors were taking antipsychotics and the burden of anticholinergic treatment. On multiple regression analysis, the only remaining factor was anticholinergic treatment: AIS≥5 was associated with constipation (odds ratio 1.80 [95% CI 1.07-3.14], P=0.027). Only 44.0% of patients were prescribed a preventive laxative, systematically in half of the cases. Above all, only 11.2% were administered this laxative (i.e., 25% of that prescribed). Digestive transit was poorly recorded in the table of constants (34.7%). We found one case of sub-occlusion as a severe case.

CONCLUSION

Constipation is common in psychiatric inpatients. The more the patient is prescribed drugs with a pronounced anticholinergic effect, the greater the risk. Alongside the preventive measures common to all psychiatric patients which must be promoted (concerning diet, physical activity, etc.), polymedication with this type of anticholinergic must be better monitored to prevent complications: prescription and administration of a preventive laxative, monitoring transit in the table of constants. Thus, a better knowledge of the subject and specific training are essential.

Effectiveness of Providing Information on Antipsychotic Medication to Patients with Psychotic Disorders: An Integrative Review

The aim of this integrative literature review is to describe the information provided to patients with psychotic disorders regarding their medication and to consider the effectiveness of providing such information. Searches of four databases identified 16 articles that met inclusion criteria. Results indicated that patients had relatively poor knowledge about their medications overall. Knowledge about side effects was found to improve significantly following education, with better knowledge leading to positive patient outcomes including increased adherence. Findings offer a comprehensive description of antipsychotic medication information provided to patients and an indication of the positive impact of information provision.

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

BACKGROUND

Clozapine-induced gastrointestinal hypomotility (CIGH) affects some 75% of patients treated with clozapine.

AIMS

To document the incidence of potentially harmful CIGH in the UK.

METHOD

We studied spontaneous UK pharmacovigilance reports recorded as clozapine-related gastrointestinal adverse drug reactions, 1992-2017.

RESULTS

There were 527 patients reported with potentially harmful CIGH; 33% (n = 172) died. Deaths averaged 1 per year 1992-1999, 5 per year 2000-2009 and 15 per year 2010-2017. Those who died were older (median 52 years v. 49 years) and had been prescribed clozapine for longer than those who recovered (median 11.3 years v. 4.8 years), but there was no difference in prescribed dose. Within the first 4 years of clozapine treatment, there were 169 reports of CIGH, of which 3% (n = 5) were fatal. At 10-14 years there were 63 reports of CIGH, of which 25% (n = 16) were fatal. Among the deaths, males were younger (median 51, range 22-89 v. median 57, range 24-89 years) with higher clozapine doses (median 450, range 100-900 v. median 300, range 12.5-800 mg/d) than females. In non-fatal CIGH, surgery was the most frequent outcome (n = 92). The procedures included appendectomy, ileostomy, total/partial colectomy, colostomy/stoma and proctosigmoidectomy. Clozapine dosage was reduced in 6 patients, stopped and restarted in 23, 'continued' in 6 and discontinued permanently in at least 76 patients.

CONCLUSIONS

The risk of serious morbidity/mortality from CIGH is substantial. The need to actively monitor bowel function and give laxatives to patients treated with clozapine is clear.

Antipsychotic-Induced Constipation: A Review of the Pathogenesis, Clinical Diagnosis, and Treatment

Antipsychotic-induced gastrointestinal hypomotility and, in particular, its manifestation of constipation are common adverse effects in patients with schizophrenia in clinical practice. Serious complications of antipsychotic-induced constipation include ileus, ischaemic bowel disease, colon perforation, aspiration pneumonia, and bacterial septicaemia, which can be life threatening if left untreated, especially in patients prescribed clozapine. The aim of this paper is to review the latest research on the epidemiology, clinical examination methods, pathophysiology, and treatment options and preventive measures for antipsychotic-induced constipation. While clinicians are normally aware of the overall side effects caused by antipsychotics, constipation is often an under-recognized condition despite its relatively high incidence and its impact on daily living. The incidence of constipation differs among individual antipsychotics, but more than 50% of patients prescribed antipsychotics suffer from constipation. Limited fluid intake, poor dietary habits, and a sedentary lifestyle can also worsen constipation. The mechanisms of antipsychotic-induced constipation may be antagonism of cholinergic, histaminergic, and serotonergic receptors, with both parent drug and metabolite(s) contributing to the effects on gastrointestinal motility. Numerous methods, mainly divided into scale evaluations and objective examinations, are applied to evaluate antipsychotic-induced constipation; however, objective examinations have a greater ability to identify cases of gastrointestinal hypomotility since there is often an under-reporting of symptoms in subjective reporting and scale evaluation due to a higher pain threshold, an inability to express pain sensations, and a lack of symptom awareness in these patients. Antipsychotic drug-induced constipation should be closely monitored in patients receiving these medications, with timely intervention to avoid serious gastrointestinal consequences. There is currently no consensus on the efficacy of laxatives in these patients. Further in-depth studies should explore the underlying mechanisms and devise optimal therapeutic approaches to minimize constipation during antipsychotic treatment.

Mental Health Nurses' Knowledge of Clozapine

Clozapine, sold under the brand name Clozaril, is an antipsychotic medication prescribed since the 1970s as an effective treatment for individuals with treatment resistive schizophrenia. Medical experts have produced extensive literature on the need for close monitoring as this medication can cause life threatening adverse effects. Mental health nurses play a vital role in the management of clozapine, however to date just one study specifically examines psychiatric/mental health nurse's knowledge of this medication. Nurses need to be aware of the adverse effects and be able to provide psychoeducation to help support and inform clients prescribed this medication. This study used a survey questionnaire. A clozapine knowledge questionnaire with 18 questions was developed by De Hert et al. to explore psychiatric/mental health nurse's knowledge on the adverse effects of clozapine. We distributed a shortened version of this knowledge questionnaire (12-multi-choice questions) to 209 mental health nurses working within one Irish Mental Health Service. One hundred and twenty-nine (n = 129) nurses completed the questionnaire with a response rate of 62%. Our results indicated that over 40% of mental nurses had not received sufficient education on clozapine medication during their formal education. We found that just 50% of participants scored over six correct questions out of 12 questions on various areas of knowledge related to clozapine medication. We identified gaps in knowledge on clozapine medication in relation to on myocarditis, epilepsy and metabolic syndrome. We highlighted gaps in mental health nurses' knowledge of clozapine medication that need to be improved in order to help clients. We advocate additional education on clozapine medication at undergraduate education and through educational packages at the service level.

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

OBJECTIVE

Despite clozapine being the most effective treatment for treatment-resistant schizophrenia (TRS), a clear explanation as to why it is underutilized and why its initiation is delayed remains unclear. The first aim of the study was to conduct a nation-wide assessment of both the psychiatrists' attitudes of the obstacles for prescribing clozapine as well as their prescription practices. The second aim was to make recommendations, based on the results obtained, for improving the Serbian clozapine guidelines.

METHODS

A questionnaire was conducted consisting of two parts. One regarded the clinical characteristics of the psychiatrists, while the second contained questions about indications for clozapine initiation, clozapine prescribing tendencies, and barriers to clozapine use. The questionnaire was sent to 302 Serbian psychiatrists.

RESULTS

With 161 out of the 302 psychiatrists returning the questionnaires, the response rate was 53.3%. Nearly 60% of the psychiatrists treated 10 or more patients with clozapine, with TRS being the most common indication. Only four psychiatrists (2.5%) had no patients currently on clozapine. Psychiatrists indicated that their fear of agranulocytosis (68%) constituted the greatest obstacle for clozapine prescription, followed closely by weight gain (56%), and sedation (39%). Despite their fear of agranulocytosis, only 83.9% of the psychiatrists monitored leukocytes regularly.

CONCLUSION

In general, psychiatrists in Serbia seem to be confident in prescribing clozapine, even in the absence of clear monitoring guidelines and the possibility of therapeutic drug monitoring. In order to reduce obstacles for clozapine prescription, monitoring laxity, and an overreliance on personal experience, we recommend three modifications of the existing clozapine guideline.

Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals

BACKGROUND

Clozapine remains the only medication licensed for treating refractory schizophrenia. However, it remains underutilized in part due to concerns regarding adverse events.

SOURCES OF DATA

Published literature.

AREAS OF AGREEMENT

Common adverse events during clozapine treatment include sedation, hypersalivation, postural hypotension, dysphagia, gastrointestinal hypomotility, weight gain, diabetes mellitus and dyslipidaemia. Rare but serious events include agranulocytosis, cardiomyopathy, myocarditis, pneumonia, paralytic ileus and seizure.

AREAS OF CONTROVERSY

It remains unclear how best to minimize clozapine-induced morbidity/mortality (i) during dose titration, (ii) from hypersalivation and (iii) from gastrointestinal hypomotility. It is also unclear how clozapine pharmacokinetics are affected by (i) gastrointestinal hypomotility, (ii) systemic infection and (iii) passive exposure to cigarette smoke. Whether monthly haematological monitoring needs to continue after 12 months of uninterrupted therapy is also a subject of debate.

GROWING POINTS

There is a need for better management of serious clozapine-related adverse events in addition to agranulocytosis. There is also a need for better education of patients and carers, general practitioners, A&E and ITU staff and others of the problems posed in using clozapine safely.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a need for more research on assessing clozapine dosage (i) as patients get older, (ii) with respect to exposure to cigarette smoke and (iii) optimizing response if adverse events or other factors limit dosage.

Antipsychotic medication side effects knowledge amongst registered mental health nurses in England: A national survey

WHAT IS KNOWN ON THE SUBJECT?: Research findings indicate the percentage of knowledge-related errors in medicines management is high, accounting for approximately 75% of all errors, with insufficient knowledge levels one of the most significant contributors of medication errors. Patients should be able to trust nurses to engage therapeutically and actively listen to their needs and concerns, responding using skills that are helpful, providing information that is clear, accurate, meaningful and free from jargon. However, without knowledge of pharmacology, it is impossible for nurses to be able to provide adequate advice. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: This study has examined an area that had not yet been systematically examined previously, which draws together previous research findings on mental health nurses' knowledge of adverse events, including side effects and medication errors, related to antipsychotic medication within NHS inpatient settings. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A recent study has found that almost three-quarters (73%) of patients taking antipsychotic medication reported side effects to some degree. This high number of people experiencing antipsychotic medication side effects is likely to compromise care, especially in situations where nurses have inadequate knowledge of side effects and are unable to provide effective advice to patients. The findings from this study allow the mental health nursing profession an opportunity to reflect on the best means to increase knowledge and increase patient safety awareness and benefits for mental health service users. ABSTRACT: Introduction Antipsychotic medications play a significant role in the treatment and recovery of people with several psychiatric disorders. However, research findings indicate mental health nurses are insufficiently knowledgeable about antipsychotic medication side effects. Aim To assess practising mental health nurses' knowledge of antipsychotic medication side effects using a Multiple-Choice Questionnaire (MCQ) across National Health Service (NHS) Trusts in England. Hypothesis Knowledge of antipsychotic medication side effects amongst registered mental health nurses is related to their academic qualification, clinical banding and length of experience. Method A national survey of registered mental health nurses was carried out using an online questionnaire which was disseminated by Research and Development departments. Results A total of 504 questionnaires were returned, 245 of which had full data and further analysed. The mean score for the sample was 14.4 and only 21 participants attained a mark of >80%. Implications for Practice Two out of three of our hypotheses (that length of experience and clinical banding are directly related to knowledge of antipsychotic medication side effects) were supported. Our study found many nurses have a suboptimal working knowledge of antipsychotic medication side effects which has the potential to compromise care. Strategies need to be put in place to enhance pharmacology knowledge.

Clozapine-Induced Gastrointestinal Hypomotility: A 22-Year Bi-National Pharmacovigilance Study of Serious or Fatal 'Slow Gut' Reactions, and Comparison with International Drug Safety Advice

INTRODUCTION

Clozapine is the preferred antipsychotic for treatment-resistant schizophrenia, but has significant adverse effects, including gastrointestinal hypomotility or 'slow gut', which may result in severe constipation, ileus, bowel obstruction, and even death. These gastrointestinal effects remain inadequately recognized.

METHODS

We reviewed all reports of serious clozapine-induced gastrointestinal hypomotility (CIGH) submitted to the Australian Therapeutic Goods Administration and New Zealand Pharmacovigilance Centre between 1992 and 2013. We extracted relevant demographic, clinical, and outcome data and derived a numerator from clozapine registries. We examined whether clozapine drug safety information in Australia, New Zealand, the US, and the UK was adequate and consistent with pharmacoepidemiologic evidence.

RESULTS

A total of 43,132 people commenced clozapine over the study period. 160 were reported as having serious gastrointestinal hypomotility with clozapine the suspected cause (37/10,000 clozapine users). Of these, 66.3% were male, age range was 17-76 years, clozapine dose range 25-1000 mg/day (mean 439 mg/day) and median duration of clozapine treatment 2.5 years. Few had received laxatives. At least 29 patients died (7/10,000 clozapine users), a reported case fatality rate of 18%. The CIGH prevalence, while similar to other smaller studies, differs significantly from clozapine prescribing information issued by regulators and pharmaceutical companies, none of which mention CIGH, and which report serious gastrointestinal complications at rates of <1/10,000, almost a 40-fold difference.

CONCLUSION

This is the largest study to date of serious CIGH. The reported prevalence of serious CIGH was 37/10,000, a likely underestimation of true prevalence. Current prescribing guidelines provide inadequate information on CIGH. This may be contributing to poor awareness and high associated morbidity and mortality. It is time regulators and manufacturers update their guidance.

Dyspepsia and constipation in patients with schizophrenia spectrum disorders

Constipation and dyspepsia are disturbing gastrointestinal symptoms that are often ignored in research on physical comorbidities of schizophrenia. The aim was to assess dyspepsia and constipation in a sample of outpatients with schizophrenia spectrum psychoses. A general practitioner performed a thorough physical health check for 275 outpatients and diagnosed constipation and dyspepsia. This study assessed the possible contribution of several sociodemographic, lifestyle, and clinical variables to constipation and dyspepsia using logistic regression analysis. This study also assessed whether these symptoms were associated with abnormal laboratory findings. The prevalence of constipation was 31.3%, and of dyspepsia 23.6%. Paracetamol (OR =3.07, 95% CI =1.34-7.02) and clozapine use (OR =5.48, 95% CI =2.75-10.90), older age (OR =1.04, 95% CI =1.01-1.06), and living in sheltered housing (OR =2.49, 95% CI =1.16-5.33) were risk factors for constipation. For dyspepsia the risk factors were female sex (OR =2.10, 95% CI =1.15-3.83), non-steroidal anti-inflammatory drugs (OR =2.47, 95% CI =1.13-5.39), and diabetes medication (OR =2.42, 95% CI =1.12-5.25). Patients with dyspepsia had lower haemoglobin and haematocrit and higher glucose values than those without dyspepsia. Patients with constipation had lower thrombocyte values than patients without constipation. However, these findings were explained by factors pre-disposing to constipation and dyspepsia. Clozapine use markedly increases the risk of constipation and may lead to life-threatening complications. In addition, analgesics and diabetes medication were related to gastrointestinal symptoms. These medications and their association to gastrointestinal symptoms should be kept in mind when treating patients with schizophrenia.