Comparison of clozapine monitoring and adverse event management in a psychiatrist-only and a clinical pharmacist-psychiatrist collaborative clinic

Exploring low clozapine C/D ratios, inverted clozapine-norclozapine ratios and undetectable concentrations as measures of non-adherence in clozapine patients: A literature review and a case series of 17 patients from 3 studies

BACKGROUND

Up to 1/2 of outpatients prescribed clozapine may be partially/fully non-adherent, based on therapeutic drug monitoring (TDM). Three indices for measuring partial/full non-adherence are proposed a: 1) clozapine concentration/dose (C/D) ratio which drops to half or more of what is expected in the patient; 2) clozapine/norclozapine ratio that becomes inverted; and 3) clozapine concentration that becomes non-detectable.

METHODS

These 3 proposed indices are based on a literature review and 17 cases of possible non-adherence from 3 samples: 1) an inpatient study in a Chinese hospital, 2) an inpatient randomized clinical trial in a United States hospital, and 3) and a Uruguayan outpatient study.

RESULTS

The first index of non-adherence is a clozapine C/D ratio which is less than half the ratio corresponding to the patient's specific ancestry group and sex-smoking subgroup. Knowing the minimum therapeutic dose of the patient based on repeated TDM makes it much easier to establish non-adherence. The second index is inverted clozapine/norclozapine ratios in the absence of alternative explanations. The third index is undetectable concentrations. By using half-lives, the chronology of the 3 indices of non-adherence was modeled in two patients: 1) the clozapine C/D ratio dropped to ≥1/2 of what is expected from the patient (around day 2); 2) the clozapine/norclozapine ratio became inverted (around day 3); and 3) the clozapine concentration became undetectable by the laboratory (around days 9-11).

CONCLUSION

Prospective studies should further explore these proposed clozapine indices in average patients, poor metabolizers (3 presented) and ultrarapid metabolizers (2 presented).

Systematic literature review of the impact of psychiatric pharmacists

Introduction

Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes.

Methods

A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version.

Results

A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes.

Discussion

The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.

Escaping the Long Shadow Cast by Agranulocytosis: Reflections on Clozapine Pharmacovigilance Focused on the United Kingdom

PURPOSE/BACKGROUND

A recent article in this journal presented a US perspective regarding the modernization of clozapine prescription and proposed an escape from the long shadow cast by agranulocytosis.

METHODS

Here, an international group of collaborators discusses a point of view complementary to the US view by focusing on worldwide outcomes of clozapine usage that may be uneven in terms of frequency of clozapine adverse drug reactions.

FINDINGS/RESULTS

Studies from the Scandinavian national registries (Finland and Denmark) did not find increased mortality in clozapine patients or any clear evidence of the alleged toxicity of clozapine. Data on clozapine-associated fatal outcomes were obtained from 2 recently published pharmacovigilance studies and from the UK pharmacovigilance database. A pharmacovigilance study focused on physician reports to assess worldwide lethality of drugs from 2010 to 2019 found 968 clozapine-associated fatal outcomes in the United Kingdom. Moreover, the United Kingdom accounted for 55% (968 of 1761) of worldwide and 90% (968 of 1073) of European fatal clozapine-associated outcomes. In a pharmacovigilance study from the UK database (from 2008 to 2017), clozapine was associated with 383 fatal outcomes/year including all reports from physicians and nonphysicians. From 2018 to 2021, UK clozapine-associated fatal outcomes increased to 440/year.

IMPLICATIONS/CONCLUSIONS

The interpretation of fatal outcomes in each country using pharmacovigilance databases is limited and only allows gross comparisons; even with those limitations, the UK data seem concerning. Pneumonia and myocarditis may be more important than agranulocytosis in explaining the uneven distribution of fatal outcomes in clozapine patients across countries.

Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review

OBJECTIVE

People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted.

RESULTS

A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported.

CONCLUSION

There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.

Pharmacists in clozapine clinics improving physical health monitoring

Introduction

People living with schizophrenia have a higher rate of comorbid physical health diseases and compared with the general population die earlier due to these diseases. A pharmacist working in an outpatient mental health clinic setting could assist with the management of physical health disease for this population. The aim of this study was to investigate whether having a pharmacist in a community clozapine clinic would improve adherence to physical health monitoring and whether this would have a positive effect on these physical health outcomes.

Methods

This retrospective observational study compared patient data from 2 clozapine clinics; one where a pharmacist engaged in medication reviews and management of medication side effects, and another that did not have a pharmacist. The rates of physical health monitoring and the changes from baseline of physical health outcomes (weight, BMI, BP, HbA1c, and lipids) were compared after the first pharmacist intervention (medication review).

Results

The pharmacist clinic had statistically higher rates of metabolic and ECG monitoring (glucose 48% vs 11%, P < .001; lipids 61% vs 7.1%, P < .001; ECG 15% vs 0%, P = .001). Positive trends in weight were identified in the pharmacist-group, although this failed to reach statistical significance.

Discussion

This study shows that pharmacists providing regular medication reviews improves physical health monitoring for patients receiving clozapine.

An investigation of new medications initiation during ambulatory care visits in patients with dementia

Background

Objectives

Methods

Results

Conclusion

•

What was already known?•

Dementia remains responsible for a large economic burden; research has shown that patients with dementia have increased utilization of ambulatory care visits before and after diagnosis.

•

Prior research in patients with dementia has focused on inappropriate prescribing, adverse drug interactions, and polypharmacy, but little work has been published investigating new medications prescribed at outpatient visits.

•

Opportunities exist for pharmacists to manage medications in the outpatient setting for patients with complex medication regimens.

•

What the study adds?•

Though fewer visits for patients with dementia provided new medications compared to visits for patients without dementia, there was no statistically significant difference in odds of a new medication being provided after adjustment for important confounders.

•

Some of the new medications more commonly provided to dementia patients include anticoagulants and antipsychotics that often require close monitoring and dosage adjustments.

•

Pharmacist led services would likely improve the care of the dementia population in an outpatient setting, but further investigation of new medication usage and the utility of pharmacists is needed.

A qualitative exploration of the barriers to and facilitators of clozapine monitoring in a secure psychiatric setting

AIMS AND METHOD

To explore the beliefs and understanding of staff and patients at a secure mental health unit regarding clozapine monitoring, and to identify barriers to and facilitators of monitoring. Qualitative semi-structured interviews and focus groups were conducted with 17 staff members and six patients.

RESULTS

Six key themes were identified. The key facilitator of effective monitoring was the motivation of staff to help patients to become independent and facilitate recovery. An important barrier was a lack of clarity around the roles of different staff groups in monitoring. Staff and patients widely supported the establishment of an in-patient clozapine clinic and perceived that it would prepare patients for discharge.

CLINICAL IMPLICATIONS

An in-patient clozapine clinic is a robust mechanism for clozapine monitoring in secure settings. The barriers and facilitators identified here could be applied to other secure units to guide their systems of clozapine monitoring.

Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders

INTRODUCTION

Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015.

METHODS

A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included.

RESULTS

A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team.

DISCUSSION

Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.

Addressing clozapine under-prescribing and barriers to initiation: a psychiatrist, advanced practice provider, and trainee survey

Clozapine use has declined, despite its superior antipsychotic efficacy in treatment-resistant schizophrenia. Implications for clozapine underutilization include suboptimal treatment outcomes and increased hospitalizations. Many barriers preventing the use of clozapine have been described in the literature, including suboptimal knowledge and poor perceptions. The aim of this study was to assess psychiatry prescribers' perception and knowledge of clozapine. A survey was distributed to advanced practice providers, psychiatrists, and trainees (i.e. residents and fellows) at 10 medical centers within the US and Canada. The survey asked respondents about their perception of clozapine use and assessed their pharmacotherapeutic knowledge of clozapine. Two hundred eleven individual submitted completed surveys of a possible 1152; a response rate of 18.3%. There were no statistically significant differences between the advanced practice provider plus psychiatrist groups and the trainee group for most perception (eight of nine) and knowledge (eight of nine) questions. The knowledge questions with the lowest scores pertained to clozapine reinitiation and myocarditis. The majority of all respondents (144, 68.2%) felt that clozapine prescribing was a burden. Findings of this study support the need for continued clozapine education regardless of a prescriber's age/experience. Future studies to assess barriers to clozapine prescribing should extend beyond academic centers.