232 - Initial work up

Initial work-up

236 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Initiation of clozapine in the community While in-­patient initiation remains the main method of starting clozapine, community initiation is fairly common in many countries. The likelihood of successful titration is similar for both methods (about 60%),1 indicating that any risks associated with reduced monitoring frequency are offset by the relatively slower initiation schedules employed in the community. Relative contraindications to community initiation ■ ■History of uncontrolled seizures, significant cardiac disease, unstable diabetes, paralytic ileus, significant blood dyscrasia, neuroleptic malignant syndrome or other disorder that increases the risk of serious adverse effects (initiation with close monitoring in hospital may still be possible). ■ ■Previous severe adverse effects on titration of clozapine or other antipsychotics. ■ ■Unreliable or chaotic lifestyle that may affect adherence to the medication or the monitoring regimen. ■ ■Significant abuse of alcohol or other drugs likely to increase the risk of adverse effects (e.g. cocaine). Essential criteria for suitability for community initiation ■ ■Is the patient likely to be adherent with oral medication and to monitoring requirements or is there support for these? ■ ■Has the patient understood the need for regular physical monitoring and blood tests? ■ ■Has the patient understood the possible adverse effects and what to do about them (particularly the rare but serious ones)? ■ ■Is the patient readily contactable (e.g. in the event of a result that needs follow-­up)? ■ ■Is it possible for the patient to be seen weekly or more often during the early titration phase? ■ ■Is the patient able to collect medication every week or can medication be delivered to their home? ■ ■Is the patient likely to be able to seek help out-­of-­hours if they experience potentially serious adverse effects (e.g. indicators of myocarditis or infection such as fever, malaise, chest pain)? ■ ■Has the patient understood what needs to be done in the event of an abnormal blood test (e.g. daily monitoring of FBC until normalisation in the case of a RED result)? Initial work-­up To screen for risk factors and provide a baseline: ■ ■Physical examination, FBC (see below), liver function tests, urea and electrolytes, lipids, glucose/HbA1c. Also, C-­reactive protein (CRP), CK, troponin, beta-­natriuretic peptide (BEN; as baseline for further tests). ■ ■ECG: particularly to screen for evidence of past myocardial infarction or ventricular abnormality.