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- QUESTION
Caitlyn Morris is 35-year-old, single African American female who has been hospitalized for the fourth time in two months after another psychotic episode including paranoid delusions and both auditory and visual hallucinations. Caitlyn lives in a group home and attends a partial hospital program at a local community mental health center. She was diagnosed with paranoid schizophrenia (ICD 10 F20.0) in her early twenties.
Caitlyn has been on multiple second-generation antipsychotics and several first-generation antipsychotics; none has been shown to be effective. During a team meeting at the hospital to discuss Caitlyn’s care, it was determined that she will be started on clozapine (Clozaril).
Questions
From your perspective as a psychiatric nurse practitioner, answer the following questions in a paper no longer than two double-spaced pages (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.Articulate why clozapine (Clozaril) would be an effective choice for Caitlyn. Under what circumstances should be clozapine (Clozaril) generally be considered? What are the FDA indications for this medication?
What baseline laboratory tests, diagnostic tests, and monitoring should you complete when treating Caitlyn? Please provide a rationale.
Articulate the dosing for clozapine (Clozaril) such as the starting dose, titration schedule, targeted dose and maximum dose, and schedule for tapering off the medication.
Describe BEN and identify patients who may have this, how lab ranges would be affected by this, and how a prescriber would monitor and manage clozapine (Clozaril) with these patients.
What is the prescriber site (URL and title) required for those who prescribe clozapine (Clozaril)? Why are prescribers required to register?
Describe the ongoing monitoring (i.e. labs, diagnostic tests, physical exams, etc.) that is required for a patient taking clozapine (Clozaril) including the frequency of this monitoring and identify the rationale for this monitoring.
Articulate the commonly expected side effects and the potentially serious adverse effects that you should monitor for and educate patients to immediately report.
| Subject | Nursing | Pages | 4 | Style | APA |
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Answer
Clozapine
Clozapine (Clozaril) is an effective choice for Caitlyn since clozapine is reserved for adults presenting with refractory schizophrenia. Besides, it is characterized with low risk of extrapyramidal symptoms and is effective for reducing the risk of schizoaffective disorder or suicidal behavior (Prescribers’ Digital Reference (PDR), 2020). U.S. Food and Drug Administration (FDA) (2014) indication for clozapine is for treatment-resistant schizophrenia. A normal baseline neutrophil count (absolute neutrophil count (ANC)) is the only test that is accepted for monitoring neutropenia. Prior to initiation of clozapine treatment, ANC value, and a complete blood count should be obtained to ensure that baseline ANC is at least 1,500/μL for patients from the general population, which refers to non-Benign Ethnic Neutropenia patients. Patients who are known to have Benign Ethnic Neutropenia (BEN) are required to have at least two baseline ANC values of 1,000/μL or more before initiation of treatment (PDR, 2020). Individuals with white blood cell count less than 1.5×109 cells per liter, which is not secondary to any disease or pathology and otherwise healthy are regarded as having BEN (Coates et al., 2020).
Neutropenia is general associated with risk factors such as bone marrow suppression, leukemia, and leukopenia. Weekly monitoring of ANC is recommended for all patients using clozapine the first six months. Exclusion of treatment is recommended for patients with low ANC below the required levels. Patients with severe neutropenia (<500/ μL) should stop using the drug unless benefits outweighs the risks (PDR, 2020). Caitlyn should be educated to identify and report with immediate effects signs and symptoms such as sore throat, fever, weakness, lethargy, and other signs of infection or bone marrow suppression (PDR, 2020).
Starting dosage is 12.5mg (taken twice or once) per day. Total daily dosage may be increased from 25mg to 50mg per day if well-tolerated. Target dose is 300mg to 400mg per day that is taken in divided dosages by the end two weeks. Maximum daily dose is 900mg. Subsequent increase or tapering in by 100mg once or twice per week (FDA, 2014).
Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program is the prescriber site for prescribing clozapine whose web address is https://www.clozapinerems.com.[63913]. All clozapine prescribers, dispensing pharmacies, and prescriber designees must be certified in the REMS program since the drug can cause severe neutropenia (PDR, 2020). Severe neutropenia may in turn increase the risk of infections and death.
It is contraindicated in patients with a history severe granulocytopenia or clozapine-induced agranulocytosis and in those who are hypersensitive to clozapine (FDA, 2014). It should be used with caution in patients with a history of seizure since it may lower seizure threshold. Besides, it should be used with caution in patients with known hepatic impairment or renal impairment. Adverse reactions include seizures, visual impairment, cyanosis, akinesia, agranulocytosis, bradycardia, peptic ulcer, tardive dyskinesia, and torsade de pointes (PDR, 2020).
References
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Coates, S., Wang, D., Pierscionek, T., Fernandes, S., Djumanov, D., Lorch, U., & Taubel, J. (2020). Time- and race-specific haematological reference intervals for healthy volunteer trials: a retrospective analysis of pooled data from multiple phase I trials. Front Pharmacol., 11, 314. https://dx.doi.org/10.3389%2Ffphar.2020.00314 Food and Drug Administration. (2014). Highlights of prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/019758s073lbl.pdf Prescribers’ Digital Reference. (2020). Clozapine – Drug summary. https://www.pdr.net/drug-summary/Clozaril-clozapine-1695
Appendix
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