Development and implementation of clozapine protocol in patients with schizophrenia in Greece

Abstract

Clozapine is an atypical antipsychotic used for the treatment of resistant schizophrenia, exhibiting significant advantages over other antipsychotic agents. Clozapine efficacy is well established in people diagnosed with schizophrenia via reducing both positive and negative symptoms. Also, is associated with a low risk of extrapyramidal side effects compared to other antipsychotics. Despite the above, clozapine is an unpopular therapeutic option for patients not previously responded to other antipsychotics, because of adverse side effects, such as hyper-salivation and weight gain or critical side effects, i.e., risk for developing neutropenia and agranulocytosis and the need for a systematic and vigilant patients' monitoring, causing discomfort to them and increased expenses to the healthcare system. The aim of the present article is to describe (a) the development of a "clozapine treatment monitoring protocol", and (b) the monitoring process applied at the Department of Psychiatry of Aghioi Anargyroi Cancer Hospital in patients under clozapine treatment. For the protocol development a systematic review of the existing literature was conducted. An advanced search in Medline, CINAHL, Scopus and Google Scholar was conducted, as well as at the National Organization of Greece for Medicines database, with the following key- words: "clozapine", "clozapine protocol", "clozapine monitoring", "clozapine guidelines". Based on this procedure, the Victorian Consensus View protocol applied in Australia was evaluated as the most appropriate since it encompasses: (a) monitoring of multiple systems based on a holistic healthcare approach towards patients, and (b) Intense cardiovascular functioning monitoring, highly relevant to the Greek population due to increased incidence of myocarditis. Overall, the necessary interventions prior and after clozapine treatment initiation are, monitoring of heamatological and cardiovascular function and related side effects, metabolic monitoring and related side effects, monitoring of metabolic adverse effects, gastrointestinal and neurological adverse effects, hepatic function monitoring and related side effects. Clozapine treatment monitoring protocol applied at special settings, e.g., Clozapine Clinics, is highly beneficial, since the risk of neutropenia, agronulocytosis is minimized, while suicidal behavior and substance use are reduced along with risky health behaviors, i.e., nicotine use and sedentary lifestyle. The current protocol may be applied by mental healthcare professionals aiming to empower individuals with schizophrenia through promoting their independency and quality of life.