Clozapine 200

Armin Moradi

2021-04-15

Previously on Clozapine…
Effects and side effects
Sedation
Sedation - treatment
Sedation - treatment 2.0
Sedation - What to do
Orthostasis
Orthostasis - treatment
Tachycardia
Tachycardia - What to do
Summary

Previously on Clozapine…

amoradi.org/public/clozapine.html
amoradi.org/public/clozapine2.html

Effects and side effects

maaaaaaaaaaaany

Sedation

Most common adverse drug reaction
can happen after titration

Sedation - treatment

qHS
slow titration
minimize sedating agents

Sedation - treatment 2.0

reduce dose
aripiprazole
stimulants

IF the patient is stable, and IF the patient is minimally symptomatic, and IF the plasma clozapine levels are on the higher end (2100-3000 mM) THEN you can think about reducing the clozapine dose (about 5% every 4 weeks). Just be careful and closely monitor for relapse. If any relapse occurs, taper should be immediately stopped, and we can think about adjunct meds.

As far as adjunct meds are concerned, there is weak evidence that adjunctive aripiprazole can reduce sedation. but should only be used on pts on clozapine monotherapy as it can interfere with other antipsychotics since it's a partial agonist (D2 displacement).

in the stimulant class, modafinil, methylphenidate, amphetamines can be helpful. Unfortunately, they are limited by abuse potential and potential for exacerbating positive psychotic symptoms, so you have to select your patients carefully, and monitor carefully.

Sedation - What to do

staaaahp benzo, antichol
500 qHS
titration

Orthostasis

systolic 20, diastolic 10
alpha1

Orthostasis - treatment

remove/reduce antihypertensives
dose adjustment
fluid intake
fludrocortisone 0.1

Tachycardia

>100

Tachycardia - What to do

orthostasis?
antichol? adrenergic?
infection? pain? illness?
first 6 months: myocarditis?
if not, atenolol 12.5

Summary

many side effects
to be continued!