Acute clozapine intoxication

Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia

Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.

Successful Treatment of an Acute High-Dose Clozapine Poisoning without Detoxication

Patient: Male, 28-year-old

Final Diagnosis: Clozapine poisoning

Symptoms: Drowsiness • hyperventilation • impaired consciousness • respiratory insufficiency • tachycadia

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine • Psychiatry

Delayed complications after severe clozapine intoxication: a case report. The pharmacokinetic profile of clozapine and it's important role in the course of symptoms

Clozapine intoxications have a varied clinical presentation and may have severe complications. Management and treatment guidelines rarely highlight the risks of delayed clinical presentations. We present the case of a 50-year-old man showing severe complications 15 hours after intoxication with 4200 mg clozapine. Treatment consisted of strict monitoring, including vital support and regular clozapine blood levels. Clinical presentations may be delayed up to 5 days after intoxication, for which strict monitoring of clinical symptoms and vital functions during this period is of major importance. We discuss the clinical course of clozapine intoxication, the value of sampling clozapine blood levels and provide an overview of the current treatment guidelines, which we suggest to update to include the management of delayed complications.

Delayed onset, protracted delirium and aspiration pneumonitis associated with a combination of clozapine and electroconvulsive therapy

Few studies reported the efficacy and safety in combination of clozapine and electroconvulsive therapy (ECT) in schizophrenia; systematic studies are lacking. Side effects like seizure, and confusional state are reported. Authors report two cases of delayed onset/protracted delirium with ECT and clozapine in schizophrenia, one of whom developed aspiration pneumonitis possibly due to clozapine hyper-salivation. Delirium improved with stopping of ECT and clozapine. Clozapine monotherapy restarted to previous dosages in both cases without recurrence of delirium. Authors recommend for careful monitoring for delirium in ECT augmentation on high dose clozapine. Unilateral ECT may be preferred for augmenting clozapine.