A retrospective study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis.

  title={A retrospective study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis.},
  author={Cecilia Casetta and Ebenezer Oloyede and Eromona Whiskey and David Taylor and Fiona Gaughran and Sukhi S. Shergill and Juliana Onwumere and Aviv Segev and Olubanke Dzahini and Sophie E. Legge and James Hunter MacCabe},
  journal={The British journal of psychiatry : the journal of mental science},
  • C. CasettaE. Oloyede J. MacCabe
  • Published 1 July 2020
  • Medicine, Psychology
  • The British journal of psychiatry : the journal of mental science
BACKGROUND Clozapine is uniquely effective in treatment-resistant psychosis but remains underutilised, partly owing to psychotic symptoms leading to non-adherence to oral medication. An intramuscular formulation is available in the UK but outcomes remain unexplored. AIMS This was a retrospective clinical effectiveness study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis over a 3-year period. METHOD Successful initiation of… 

Clinical Experience With Intramuscular Clozapine

IM clozapine may facilitate successful transition to oral clozAPine in most patients, and it definitely represents a valuable tool for addressing refusal of oral clazapine in patients with treatment-refractory schizophrenia.

Treatment-Resistant Schizophrenia: Definition, Predictors, and Therapy Options.

Earlier and broader use of clozapine in patients with TRS is an important measure to improve outcomes of patients with this most severe form of the illness, and studies indicate that response rates are higher when clozAPine is initiated earlier in the treatment course.

Alternative Routes of Administration of Clozapine

The administration of clozapine (suspension or crushed tablets) via enteral feeding tubes (predominantly nasogastric) has been reported both in medically unwell patients and in patients refusing clozAPine, and is likely to be superseded by intramuscular clozal administration.

Clozapine resistant schizophrenia: Newer avenues of management

The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS, and newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered.

Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital

Even in this extreme group of patients with treatment resistant schizophrenia, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients, according to a case series of 14 consecutive patients rechallenged in a high-secure psychiatric hospital.

New approaches to antipsychotic medication adherence – safety, tolerability and acceptability

New and varied approaches to antipsychotic treatment adherence have the potential to make a significant impact on morbidity in this often difficult-to-treat population.

Intramuscular clozapine in the acute medical hospital: Experiences from a liaison psychiatry team

It is shown that intramuscular clozapine is a safe and effective treatment for patients with serious mental health illness in the acute medical hospital.

Combination With Long-Acting Injectable Antipsychotics and Utilization of Nonstandard Formulations as Compliance Enhancing Methods for Clozapine Users

In a case series, illness severity and the number of hospitalization per year significantly decreased after the combined treatment, besides a significant improvement in the functioning scores, and oral-dissolving tablets or oral liquid formulations of clozapine have insufficient evidence for clinical practice.

The conundrum of therapeutic intoxication

Intramuscular clozapine is most useful as part of a pre-discussed and well-planned multidisciplinary team initiation regimen and should be done with appropriate safeguards, in appropriate settings, and following a thorough appraisal of risks versus benefits.

Should intramuscular clozapine be adopted into mainstream clinical practice?

Summary Clozapine is under-used in the UK, and Casetta et al's recent paper in the BJPsych adds to a growing number of small studies that support the use of intramuscular clozapine to initiate and



Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation

Substantial delays to clozapine initiation remain and antipsychotic polypharmacy and high doses are commonly used prior to clazapine, despite treatment guidelines.

Compulsory treatment with clozapine: a retrospective long-term cohort study.

Evaluation of the effectiveness and acceptability of intramuscular clozapine injection: illustrative case series

It is shown that intramuscular clozapine can be used safely and effectively when the oral route is initially refused, and the use, efficacy and safety of this treatment modality is described.

Results of phase 3 of the CATIE schizophrenia trial

Association With Hospitalization and All-Cause Discontinuation Among Patients With Schizophrenia on Clozapine vs Other Oral Second-Generation Antipsychotics: A Systematic Review and Meta-analysis of Cohort Studies.

A systematic review and meta-analysis of cohort studies to compare various outcomes of clozapine vs oral NC-SGAs in schizophrenia or schizoaffective disorder found that, despite more severely ill patients being treated with clozAPine, use of clazapine was associated with better efficacy outcomes and better risk of hospitalization risk.

An algorithm-based approach to first-episode schizophrenia: response rates over 3 prospective antipsychotic trials with a retrospective data analysis.

A high response rate (75%) to initial antipsychotic treatment in first-episode schizophrenia is confirmed and a subsequent trial with clozapine is clearly warranted, although it remains unclear whether outcome would be further enhanced if it were used earlier in the treatment algorithm.

Clozapine Treatment and Offending: A Within-Subject Study of Patients With Psychotic Disorders in Sweden.

It is found periods of mirror-image observation time with clozapine treatment were associated with a much lower rate of violent offending compared to periods before treatment, and in patients with psychotic disorders, clozAPine treatment isassociated with a lower rate with olanzapine.

A prospective, multicenter study of patients' refusal of antipsychotic medication.

Treatment refusal had negative effects on the hospital milieu and on the patient; refusers were more likely to require seclusion or restraint and had longer hospitalizations than treatment acceptors, and most refusal episodes ended with voluntary acceptance of treatment.

Clozapine and Long-Term Mortality Risk in Patients With Schizophrenia: A Systematic Review and Meta-analysis of Studies Lasting 1.1–12.5 Years

Continuous clozapine treatment in schizophrenia patients was associated with a significantly lower long-term all-cause mortality rate compared to other antipsychotic use, giving reason to re-evaluate the hesitancy to prescribe clozAPine in regular care settings.