Annual Meeting Will Feature a Trio of Sessions on Clozapine

Despite evidence that clozapine is the most effective antipsychotic for patients with treatment-resistant schizophrenia, the medication remains infrequently prescribed in the United States. The hesitancy to prescribe this drug stems from longstanding issues, such as concerns over clozapine’s rare but potentially severe side effects, as well as administrative burdens related to following clozapine’s FDA-required Risk Evaluation and Mitigation Strategy (REMS).

APA is offering three sessions on clozapine at the 2022 Annual Meeting that will provide up-to-date information for both clinicians and administrators. The sessions are sponsored by APA’s SMI Adviser and organized by Robert Cotes, M.D., an associate professor of psychiatry at Emory University School of Medicine and director of the Clinical & Research Program for Psychosis at Grady Memorial Hospital.

Two of the sessions will take place on Sunday, May 22, and present basics on clozapine. Cotes said the first session will be geared toward the individual prescriber and should make any attendee comfortable with evaluating patients; titrating patients’ doses as needed; and navigating the requirements of clozapine REMS, which was updated last year and has proven problematic for physicians, pharmacies, and patients.

Cotes noted that even physicians who currently prescribe clozapine are likely to benefit from the session. “We will address new and important clinical issues, such as what one should do if a clozapine patient gets COVID,” he said. “This includes a potentially significant drug-drug interaction that can occur between clozapine and the recently approved COVID therapeutic Paxlovid.”

The second Sunday session will explore key steps that administrators can take to set up a clozapine clinic or expand their existing clozapine operations. Cotes said this session builds off a recent survey from SMI Adviser on the characteristics of 32 existing clozapine clinics.

For anyone interested in a deeper dive into clozapine pharmacology, the third session offered this year will examine the ethnopsychopharmacology of clozapine. Ethnopsychopharmacology is the study of how genetic, environmental, and cultural differences among people of diverse racial/ethnic backgrounds may influence their response to medications.

One issue that may impact clozapine prescribing is a condition known as benign ethnic neutropenia (BEN), which causes people to have naturally low levels of neutrophils (a type of white blood cell). This condition is more prevalent in people of African or Middle Eastern descent. There has been a misconception among some doctors that people with BEN are at higher risk of agranulocytosis, a rapid and potentially life-threatening drop in white blood cells that rarely occurs in clozapine patients. This belief may partially underlie why psychiatrists underprescribe clozapine to minority populations.

Current evidence indicates that people with BEN can be safely given clozapine, and the ethnopsychopharmacology session will discuss how to evaluate and treat patients with this condition using clozapine. The session will also discuss other genetic variations that may impact clozapine metabolism along with when and how to measure patients’ blood clozapine levels.

“In my experience, physicians have little trouble maintaining patients on clozapine; the hesitancy comes primarily from identifying which patients are most likely to benefit and then initiating the treatment,” Cotes said. “I think these sessions can help people get over that hump.” ■