Academic pharmacist Nataly Martini highlights the importance of understanding non-Hodgkin lymphoma and pharmacists’ roles in managing this condition
CLASStime: Clozapine dispensing
Clozapine is an atypical antipsychotic that is effective for treatment-resistant schizophrenia. However, it is associated with serious adverse reactions and requires close monitoring, particularly during initiation. In this article, Amber Young and Emma Smith explain the roles of the pharmacist in supporting patients taking clozapine
1. Stahl S. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, 5th Edition. Cambridge, UK: Cambridge University Press; 2021.
2. World Health Organisation. Schizophrenia. 10 January 2022.
3. Meyer JM, Stahl SM. The Clozapine Handbook: Stahl’s Handbooks. Cambridge, UK: Cambridge University Press; 2019.
4. Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry 2016;50(5):410–72.
5. Mellsop G, Tapsell R, Menkes DB. Testing a hypothesis arising from the epidemiology of schizophrenia in New Zealand. Gen Psychiatr 2019;32(2):e100048.
6. Gibb S, Brewer N, Bowden N. Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data. N Z Med J 2021;134(1537):66–83.
7. Taitimu M, Read J, McIntosh T. Ngā Whakāwhitinga (standing at the crossroads): How Māori understand what Western psychiatry calls "schizophrenia". Transcult Psychiatry 2018;55(2):153–77.
8. Howes OD, McCutcheon R, Agid O, et al. Treatment-resistant schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry 2017;174(3):216–29.
9. Masdrakis VG, Baldwin DS. Prevention of suicide by clozapine in mental disorders: systematic review. Eur Neuropsychopharmacol 2023;69:4–23.
10. Stone JM, Raffin M, Morrison P, McGuire PK. Review: The biological basis of antipsychotic response in schizophrenia. J Psychopharmacol 2010;24(7):953–64.
11. Hayes RD, Downs J, Chang CK, et al. The effect of clozapine on premature mortality: an assessment of clinical monitoring and other potential confounders. Schizophr Bull 2015;41(3):644–55.
12. Medsafe. Clozapine Close Monitoring Required. 10 June 2015.
13. SafeRx. Clozapine. Safe Prescribing – We Are Counting On You. September 2022.
14. New Zealand Formulary. NZF v134, 1 August 2023. nzf.org.nz
15. Deho IF. IM Clozapine Protocol. NHS; July 2020.
16. Medsafe. Restrictions on the Supply, Prescribing or Administration of Medicines under the Medicines Act 1981 and Misuse of Drugs Regulations 1977. 19 June 2023.
17. BPACnz. Clozapine: safe prescribing. 15 September 2017.
18. Douglas Pharmaceuticals Ltd. Clopine. New Zealand Data Sheet, 2021.
19. Douglas Pharmaceuticals Ltd. Versacloz. New Zealand Data Sheet, 2021.
20. Viatris Ltd. Clozaril. New Zealand Data Sheet, 2023.
21. New Zealand Compounding Working Group. Clozapine suspension 20 mg/mL (100 mL). New Zealand standardised oral formulation batch sheet, 2019.
22. Every-Palmer S, Ellis PM, Nowitz M, et al. The Porirua Protocol in the treatment of clozapine-induced gastrointestinal hypomotility and constipation: A pre- and post-treatment study. CNS Drugs 2017;31(1):75–85.
23. Clozapine Dispensing in Community Pharmacy - On Demand. Pharmaceutical Society of New Zealand, 2020.
24. Tiihonen J, Lönnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009;374(9690):620–27.
25. Taylor DM, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. Wiley-Blackwell, UK; 2018.
26. Mizuno Y, Suzuki T, Nakagawa A, et al. Pharmacological strategies to counteract antipsychotic-induced weight gain and metabolic adverse effects in schizophrenia: a systematic review and meta-analysis. Schizophr Bull 2014;40(6):1385–403.
27. Sockalingam S, Shammi C, Remington G. Clozapine-induced hypersalivation: a review of treatment strategies. Can J Psychiatry 2007;52(6):377–84.
28. Meyer J. Clozapine-Induced Sialorrhea: Why Is It Important and How Should You Manage It? In: Managing the Nonhematological Adverse Effects of Clozapine. Psychopharmacology Institute, 1 April 2018.
29. Sugawara Y, Kikuchi Y, Yoneda M, Ohno-Shosaku T. Electrophysiological evidence showing muscarinic agonist-antagonist activities of N-desmethylclozapine using hippocampal excitatory and inhibitory neurons. Brain Res 2016;1642:255–62.
30. Freudenreich O, Beebe M, Goff DC. Clozapine-induced sialorrhea treated with sublingual ipratropium spray: a case series. J Clin Psychopharmacol 2004;24(1):98–100.
31. Bonney WW, Gupta S, Hunter DR, Arndt S. Bladder dysfunction in schizophrenia. Schizophr Res 1997;25(3):243–49.
32. LabPLUS Test Guide. Clozapine. Auckland District Health Board, 2022.
33. Kingsley Green Pharmacy and Medicines Optimisation Team. Clozapine Plasma Level Monitoring Guide. March 2019.