# 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
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■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).
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■Previous severe adverse effects on titration of clozapine or other antipsychotics.
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■Unreliable or chaotic lifestyle that may affect adherence to the medication or the 
monitoring regimen.
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■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
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■Is the patient likely to be adherent with oral medication and to monitoring requirements 
or is there support for these?
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■Has the patient understood the need for regular physical monitoring and blood tests?
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■Has the patient understood the possible adverse effects and what to do about them 
(particularly the rare but serious ones)?
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■Is the patient readily contactable (e.g. in the event of a result that needs follow-­up)?
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■Is it possible for the patient to be seen weekly or more often during the early titration 
phase?
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■Is the patient able to collect medication every week or can medication be delivered to 
their home?
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■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)?
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■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:
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■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.