Schizophrenia (Oxford Psychiatry Library) by David Castle & Peter Buckley

Author:David Castle & Peter Buckley
Language: eng
Format: mobi
ISBN: 9780198712831
Publisher: Oxford University Press
Published: 2015-03-14T22:00:00+00:00

Figure 8.3 Clozapine monitoring

Box 8.5 White blood count (WBC) and neutrophil count (NC) cut-offs with

clozapine

tmentsea

• Green: WBC > 3.5 and NC > 2.0: continue to prescribe, and continue weekly or monthly tr

blood tests, dependent upon stage of treatment.

• Amber: WBC 3.0–3.5 and/or NC .5–2.0: continue to prescribe, but perform blood tests ysical

twice weekly till normalizes.

ph

• Red: WBC < 3.0 and/or NC < .5: STOP clozapine immediately; discuss with haematologist regarding best action; continue monitoring as advised by haematologist.

and

gical

response to a particular agent, the use of combinations has clinical appeal. For example, studies have shown that adding aripiprazole to clozapine can allow a reduction in the clozapine dose, with subsequent weight reduction.

Pharmacolo

Another area where combinations are sometimes justified is in people who simply do not 8

respond optimally to any single agent, and in whom a combination is effective and well tolerated. Having said this, the preferred approach would be of optimal dosing of a series of single agents for a reasonable period (6–2 weeks) before resorting to combinations. A recent study CHAPTER

by Correll and colleagues showed a benefit for antipsychotic polypharmacy in some patients; 64

and Essock and colleagues tried switching patients on more than one antipsychotic, to a single agent and found that, whilst some managed on only one drug, others needed to return to their original combination therapy. Another recent pharmacovigilence study showed similar long-term mortality risk between antipsychotic monotherapy and polypharmacy, although concomitant use of benzodiazepines was associated with greater (premature) mortality.

Combination therapies are mostly pragmatic, and do carry the risk of drug–drug interactions and worsening of other side effects, but used judiciously they can be of utility to individual patients.

Suboptimal response to clozapine is a particular circumstance which leaves the clinician with limited options, and adjunctive use of relatively ‘clean’ dopamine D receptor antago-2

nists (notably risperidone and amisulpride) has currency in clinical practice. The evidence for the use of adjunctive risperidone is equivocal at best, and there is very little well-researched data on amisulpride augmentation. Having said this, many clinicians have seen benefits from these combinations at an individual patient level. One of the plusses is that any EPSE-inducing properties of the adjunctive agent are usually reduced by the inherent properties of clozapine, including its strong antimuscarinic effects.

8.6 What adjunctive pharmacological treatments

might be useful?

It is very common in clinical practice for people with schizophrenia to be prescribed more than one psychiatric medication. Adjunctive use of mood-stabilizing anticonvulsants or lithium is particularly popular. Certainly in patients with a strong affective flavouring to their illness, this has strong appeal, though again side effects of the combinations can be problematic (e.g. weight gain). Valproate also appears to have efficacy against aggressive behaviours, and has been shown to ‘bring forward’ antipsychotic response in the acute phase of treatment.

Lamotrigine is favoured as an adjunct in many European countries, and there is some (somewhat inconsistent) research evidence to support this practice; care needs to be taken to titrate

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