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).
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 baseline laboratory tests, diagnostic tests, and monitoring should you complete when treating Caitlyn? Please provide a rationale.
Articulate the dosing for clozapine (Clozaril).
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 that is required for a patient taking clozapine (Clozaril) and identify the rationale for this monitoring.
Articulate the side effects that you should monitor for.
Paranoid Schizophrenia is a type of mental illness characterized majorly by schizophrenia symptoms such as delusion and hallucination (Winckel & Siskind, 2017). These symptoms block the memory from differentiating between what is real and what is not. As a rare condition of Schizophrenia usually occurs in about two percent of the population affecting both adults and adolescents. Treating the condition with antipsychotics sometimes proves ineffective as patients develop resistance or fail to respond adequately to the antipsychotic drugs; however, trials have shown that Clozapine is the most effective antipsychotic for reducing the schizophrenia symptoms on patients with treatment resistance. Notwithstanding, it is critical to articulate the reasons for choosing Clozapine to manage Caitlyn’s conditions stating the baseline laboratory tests needed before commencing the treatment and the monitoring procedures for effective response.
Why Clozapine (Clozaril) would be an Effective Choice for Caitlyn
Caitlyn constitutes one-third of patients with Schizophrenia who generally have a low response to the many standard antipsychotic treatments and therapies (Winckel & Siskind, 2017). Having participated in several second-generation antipsychotics and multiple first-generation antipsychotics without much success, clozapine treatment passes as a valid choice for managing her condition subject to adequate dosing and monitoring. Clozaril is considered as a superb treatment when patients have persistent symptoms of Schizophrenia even after participating in other standard antipsychotics. Similarly, Clozapine treatment is considered in situations where the patient is suffering from recurrent suicidal imaginations (Winckel & Siskind, 2017). Therefore, Clozaril treatment is recommend for Caitlyn, who might have suffered adverse negative effects from antipsychotic medications such as low blood pressure and lowered white blood cell count.
The manifestation of clozapine side effects on patients such as high fever, neutropenia, agranulocytosis, and liver enzyme elevation demands that a baseline laboratory and diagnostic test be conducted before admitting Caitlyn Morris into the program. This makes it necessary to conduct a general laboratory test on Caitlyn cardiovascular to examine the absolute neutrophil count required to initiate Clozapine (De Berardis et al., 2018). Furthermore, diagnostic test on her body mass index and drug levels in the blood will help in monitoring the insulin resistance and diabetes that might affect the treatment and the therapeutic drug range. Additionally, for this case, a pregnancy test is essential to ascertain her legibility for the procedure, which could be harmful to the pregnancy. Clozaril treatment starts at low dose of about 25mg/day, three times a day to lower the autonomic effects like orthostatic hypotension, and gradually increases depending on the plasma levels to about 350mg (De Berardis et al., 2018). Once the target dose is attained, the patient response is monitored to check on the need for adjustments. Regular dozing for Clozapine is essential in reducing the symptomatic response and side effects of the treatment like sedation.
Clozapine use is associated with side effects, some very severe such neutropenia which, if not managed, results in fatal infections (Samara et al., 2018). Registering the patient on a certified clozapine risk evaluation and mitigation strategies benefit the patient in obtaining an absolute neutrophil count following the prescription plans. Further, prescriber registration is required to allow for easy dispensation of drugs, which follows the treatment rationale. Lastly, clinicians need to register to show that they are competent to prescribe the medicine before getting certification for dispensation. The prescriber site (URL and title) required for those who prescribe clozapine (Clozaril) is: (https://www.clozapinerems.com/CpmgClozapineUI/home.u Clozapine REMS).
Ongoing Monitoring for patients taking clozapine (Clozaril)
Because of the dangers associated with Clozaril use, there are standard monitoring areas for patients taking Clozapine such as the neutrophil count to avoid dangers of fatal neutropenia, cardiovascular health to identify Clozapine related myocarditis, and the patient’s metabolism to detect and prevent treatment-related hyperglycemia (Samara et al., 2018). In the Caitlyn case, checking out for side effects that might result from the drug such as neutropenia by having regular blood screening, pulmonary embolism, which may lead to death if not noticed earlier and weight gain that might affect insulin sensitivity are inevitable.
In conclusion, the paranoid schizophrenia disorder characterized by partial or full resistance to antipsychotic drugs is the foundation for clozapine usage. Studies have shown a remarkable response from patients using this drug when administered under strict supervision. Despite the health benefits, health practitioner should look out for adverse side effects of the treatment that might disqualify the patient from continuing with the procedure, such as weight gain and agranulocytosis.
De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., … Di Giannantonio, M. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine. Therapeutic advances in drug safety, 9(5), 237–256. doi:10.1177/2042098618756261
Samara, M. T., Klupp, E., Helfer, B., Rothe, P. H., Schneider-Thoma, J., & Leucht, S. (2018). Increasing antipsychotic dose versus switching antipsychotic for non response in schizophrenia. The Cochrane database of systematic reviews, 5(5), CD011884. doi:10.1002/14651858.CD011884.pub2
Winckel, K., & Siskind, D. (2017). Clozapine in primary care. Australian prescriber, 40(6), 231–236. doi:10.18773/austprescr.2017.067