Clozapine initiation and re-titration: Specialist Mental Health (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Objectives

This sets out the criteria to be followed by healthcare professionals in Highland Health and Social Care Partnership for the prescribing, administration and monitoring of clozapine. The aim of this document is to enable the safe and effective use of clozapine in the treatment of mental illness.

Scope

These guidelines are intended to be used in all situations where treatment with clozapine is either initiated or re-titrated on an in-patient ward or in a community setting. This guideline is for all mental health workers who are involved in any aspect of the prescribing, administering or monitoring of clozapine.

Audience

  • HHSCP only
  • Specialist secondary care use only
  • Adults only
  • Clozapine is a second generation antipsychotic licensed for treatment-resistant schizophrenia, and for psychosis during the course of Parkinson’s disease.
  • For a patient to be considered eligible for clozapine they must be assessed by a psychiatrist and have failed to respond adequately to treatment with at least two other antipsychotics (one of these must be a second generation antipsychotic).
  • The Medicine and Healthcare products Regulatory Authority (MHRA) has restrictions on its prescribing. This includes regular full blood count (FBC) monitoring, due to the risk of neutropenia and agranulocytosis.
  • Clozapine monitoring services provide centralised monitoring of leucocyte and neutrophil counts, which is a mandatory requirement for all patients in the UK who are treated with clozapine.
  • Failing to follow correct procedures could result in harm to patients.

Due to some of the adverse reactions associated with clozapine (e.g. orthostatic hypotension, tachycardia, sedation, seizures, hyperthermia, etc.) it is advised that initiation of treatment is commenced when a patient is admitted to a hospital as an in-patient.

However, this is no longer a mandatory, regulatory requirement. When this is not possible, eg, if the patient is reluctant to be admitted or beds are unavailable, initiation can be carried out in the community. With intensive support and a coordinated team approach many patients have been successfully started on clozapine in this manner.

NB: Community initiation is managed by the Specialist Mental Health Service only as described in that section below. 

Indications, cautions & contraindications and interactions

Therapeutic indications

  • Clozapine is indicated in patients with treatment-resistant schizophrenia and patients with schizophrenia who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics.
  • Treatment resistance is defined as a lack of satisfactory clinical improvement despite the use of adequate doses of at least two different antipsychotic agents, including an atypical antipsychotic agent, prescribed for adequate duration.
  • Clozapine is also indicated in psychotic disorders occurring during the course of Parkinson's disease, in cases where standard treatment has failed.

Off-label use of clozapine

  • The consultant psychiatrist for an individual patient must accept clinical responsibility for any off-label use of clozapine.
  • The appropriate clozapine monitoring service (see registration, below) must be contacted prior to prescribing off-label by the consultant. An 'Off-licence treatment agreement form' should be completed.

Contraindications, Special Precautions and Interactions with clozapine

  • Full details of contraindications, special precautions and interactions can be found on the summary of product characteristics for Clozaril®, Zaponex® or Denzapine®.
  • NB: Community clozapine initiation should be avoided in patients where a caution or contraindication (off-label use) exists.

Pre-treatment and registration

Pre-treatment

  • A full medical history should be taken, particularly noting diabetes or haematological disorders. Previous medication adverse effects should also be noted and, if any medications are being continued, then any possible interactions with clozapine should be considered.
  • Where possible, a baseline psychiatric assessment should be performed using a recognised rating scale, eg, PANSS, CGI-SCH, mKGV.
  • Clozapine is subject to ongoing mandatory FBC monitoring due to the risk of neutropenia and agranulocytosis. A baseline FBC is required to register the patient with the appropriate clozapine monitoring service. A FBC must be less than 10 days old to register and commence clozapine.

In line with the NHS Scotland Clozapine Physical Health Monitoring Standards, the following baseline tests and investigations must be undertaken prior to commencing clozapine:

Lab tests Physical tests Other
CRP Blood pressure ECG
FBC Pulse Smoking status
Fasting glucose Weight Bowel function
Lipids   Pregnancy status
LFTs   Drug interactions
Troponin I   Check exclusion criteria (SPC)
U&Es    

Registration

  • All patients must be registered with a clozapine monitoring service.
    This is in line with the requirements of the MHRA and assists with maintaining patient safety, providing information and advice, controlling distribution and preventing inappropriate rechallenges with clozapine.
  • Prescribers and dispensing pharmacies must be registered with the clozapine monitoring service.
  • New Craigs Hospital is the registered pharmacy site within North Highland for all patients prescribed clozapine. 
  • Registration forms for patients and prescribers can be obtained from New Craigs Pharmacy and can also be found on the monitoring service websites.

If out of hours, contact the appropriate clozapine monitoring service (available 24 hours) to confirm registration status before commencing/ recommencing clozapine:

  • Clozaril Patient Monitoring Service (CPMS) on Tel: 0845 769 8269
  • Denzapine Monitoring Service (DMS) on Tel: 0333 200 4141
  • Zaponex Treatment Access System (ZTAS) on Tel: 0207 3655842

Prescribing and supply of clozapine

Clozapine must be prescribed by, or under the supervision of, a Consultant (Psychiatry, Neurology, Learning Disabilities) or a Specialist Doctor (or equivalent grade) in accordance with the licensed indications.

The clozapine monitoring service must be notified of any off-label use of clozapine during the registration process and an 'Off-licence treatment agreement form' should be completed.

  • Clozapine should not be prescribed or dispensed until registration with the clozapine monitoring service is confirmed.
  • When registered, the patient’s consultant and the dispensing pharmacy will receive notification (usually via secure email).
  • New Craigs Pharmacy Department (01463 253606) should be contacted to confirm appropriate registration is complete before clozapine is prescribed.

Ongoing supplies of clozapine will be issued to patients from New Craigs pharmacy once a valid FBC is available (see monitoring, below). For patients in the community this supply will be sent by Royal Mail Special Delivery.

In-patient Initiation

Many of the adverse effects of clozapine are dose-dependent and associated with speed of titration. Adverse effects also tend to be more common and severe at the beginning of therapy. To minimise these problems it is important to start treatment at a low dose and to increase dosage slowly.

It is recommended that clozapine titrations should NOT be initiated over a weekend, where possible, to ensure that appropriate monitoring can be undertaken.

Treatment Resistant Schizophrenia

Recommended starting regimen for adults aged 18 to 59 years:

  • Day One: 12.5mg at night
  • Day Two: 25mg at night
  • Day Three: 37.5mg at night
  • Day Four: 50mg at night for three days
  • Thereafter: increase by 50mg every three days to target dose.

Target dose:

  • Female non-smokers: 250mg/day
  • Male non-smokers: 350mg/day
  • Female smokers: 450mg/day
  • Male smokers: 550mg/day
  • Lower doses may be required in the elderly (see below).

Titration: 

  • A plasma level of 0.35mg/L is generally considered the minimum target plasma level to ensure an adequate treatment trial, however response may occur at a lower plasma level (see therapeutic drug monitoring, below). 
  • Slower titration may be necessary where sedation or other dose-related side effects are severe, in the elderly, the very young, those who are physically compromised or those who have poorly tolerated other antipsychotics.
  • If the patient is not tolerating a particular dose, decrease to one that was previously tolerated.
  • If the adverse effect resolves, increase the dose again but at a slower rate.
  • At doses above 200mg daily, consideration should be given to divided doses. The total daily dose may be divided unevenly, with the larger portion at bedtime. The BNF maximum total daily dose is 900mg.

Recommended starting regimen for adults aged 60 years and over:

  • Slower titration may be necessary, particularly if frail.
  • Consideration should be given to a starting dose of 12.5mg at night and increasing in steps of 25mg every 3 days.
  • Aim for a low maintenance dose (100 to 300 mg daily).

Polypharmacy occurs more often in the elderly, and increases the risk of pharmacokinetic/ pharmacodynamic interactions. This may result in an unpredictable effect on clozapine plasma levels. Assess clozapine plasma level (see therapeutic drug monitoring, below), especially when dosing above 200 to 300 mg daily.

Psychosis in Parkinson’s disease:

  • Starting dose: 6.25mg to 12.5mg, taken at bedtime.
  • Increase in steps of 12.5mg up to twice weekly, adjusted according to response.
  • The mean effective dose is usually between 25mg and 37.5 mg daily, given as a single dose in the evening.
  • A dose of 50mg daily should only be exceeded in exceptional circumstances, with increments of 12.5mg
    weekly, to a maximum total daily dose of 100mg.

Community initiation

Community initiation is managed by the Specialist Mental Health Services for those patients living in the community. All prescribing is carried out by the prescriber registered with clozapine monitoring service and supplied from New Craigs Pharmacy, as above. 

Following the European harmonisation of the clozapine Summary of Product characteristics (SPC), there is no longer a mandatory regulatory requirement for in-patient initiation of clozapine. Community initiation can provide effective treatment and allow patients to be treated in the environment most appropriate for them.
Every patient should be evaluated individually before community initiation is started. The medical assessment is no different than the normal procedure for in-patients, with consideration given to the following points:

  • Patients should be considered suitable (by the consultant psychiatrist) for out-patient care in view of their current symptomatology and safety risks.
  • Community clozapine initiation should be avoided in patients where a caution or contraindication exists.
  • Patients should consent to clozapine treatment and blood tests, and be aware of, and agree to, the
    necessity for daily attendance and/or home visits.
  • The team of healthcare providers and family/ social carers should be motivated and supportive.
  • It is recommended that the patient is not left alone during the first week of treatment. Ideally, someone (family/ social carer) should stay overnight with the patient during that period. The main reason for this is orthostatic hypotension (with or without syncope), which is common during clozapine therapy, especially during early titration. In rare cases, orthostatic hypotension can lead to profound collapse, which may be accompanied by cardiac and/or respiratory arrest.

Service Requirements

All members of the health care team: carers, family members and GP should be provided with all the necessary information about clozapine; including monitoring requirements, time to improvement and recovery, an understanding of the possible side effects that may be expected and they should be given an emergency contact number. There should also be a backup plan in place in the event of patient defaulting from visits or becoming non-compliant.

The starting regimens, as above, can be used, however clozapine SHOULD START ON A MONDAY and the dose of clozapine SHOULD NOT BE INCREASED AT THE WEEKEND.

A Clozapine Community Initiation Support Plan should be in place (see sample support plan).

Monitoring

FBC monitoring

All patients prescribed clozapine will have FBC monitoring according to the marketing authorisation and the national clozapine standards as follows:

FBC monitoring schedule
Baseline  At registration
Weekly For the first 18 weeks
Fortnightly From weeks 19 to 52
Every 4 weeks After 52 weeks of treatment, for as long as clozapine continues
Twice weekly In the event of an amber result (see below). Continue until green
Daily In the event of a red result (see below). Continue until 2 consecutive green results
  • A FBC must be performed within 10 days prior to initiating clozapine treatment. The WBC count must be ≥3.5x109/L and neutrophils ≥2.0x109/L before clozapine can be started.
  • After the start of clozapine treatment, regular WBC count and ANC must be performed and monitored throughout treatment and for four weeks after discontinuation of clozapine. FBCs are analysed locally at Raigmore Hospital. 
  • This monitoring for in-patients and Inverness out-patients is routinely undertaken at the Clozapine Clinic at New Craigs Treatment Centre. This runs every Monday morning on a drop-in basis.
  • Outwith the clozapine clinic, the sector doctor or duty doctor may be required to take clozapine bloods for these patients if the treatment centre nurse is unavailable.
  • Arrangements must be in place for all other out-patients to have this monitoring carried out at an ITR or GP Practice.
Blood cell count (x109/L) Action required
WBC ≥3.5
and
Neutrophils ≥2.0		 GREEN RESULT
  • Continue clozapine treatment
WBC 3.0 to 3.5
and/or
Neutrophils 1.5 to 2.0		 AMBER RESULT
  • Continue clozapine treatment.
  • FBC twice weekly until GREEN RESULT is obtained.
WBC <3.0
and/or
Neutrophils <1.5		 RED RESULT
  • Immediately stop clozapine treatment.
  • FBC daily until 2 consecutive, confirmed GREEN RESULTS obtained.
  • Monitor for infection.
  • IF RED RESULT CONFIRMED, DO NOT RE-EXPOSE THE PATIENT.
  • If a patient has had a confirmed (second consecutive) red result, the patient should not routinely be restarted again in the future with any brand of clozapine. The patient’s details are entered onto the Central Non Rechallenge Database (CNRD), which is a shared database of all clozapine brands in the UK.
  • Re-challenge after a confirmed neutropenia/ agranulocytosis must be agreed with the clozapine monitoring service. It would be considered off-label treatment and requires an 'Off-licence agreement form', signed by the registered Consultant Psychiatrist.

Physical Health Monitoring

The following measurements must be taken during the initial titration of clozapine:

Day of titration Observations Frequency
Days 1 to 7* NEWS including sitting and standing blood pressure Pre-dose and a minimum of one hour after each dose
Days 8 to 15* NEWS including sitting and standing blood pressure To be agreed with the medical team

*The “GASS for Clozapine” or other recognised side-effect questionnaire for antipsychotic medication can be used during initiation and regularly thereafter.

  • Constipation must be assessed at every contact with the patient during the titration phase and beyond. The patient should be proactively asked daily if bowels have moved. If not, assess other dietary reasons or causative medicines and prescribe laxatives if needed.
  • Where clozapine initiation has been carried out in the community, patients should either attend a healthcare facility or be visited by a healthcare professional every weekday for a minimum of TWO weeks for physical health monitoring. Thereafter, monitoring may be undertaken on alternate days until a stable dose is reached.
  • If severe side effects occur (see below), daily monitoring should be continued until these have disappeared.
  • The actual duration of this period is subject to medical review. A doctor should see the patient regularly, a minimum of ONCE weekly for the first 4 weeks.
  • Contact medical staff to discuss management if:
Result Rationale Response to abnormal results
Temperature is ≥ 38°C Up to 20% incidence of benign fever during early weeks of clozapine therapy.

Isolated fever is not a good reason for stopping
clozapine.

Consider appropriate investigations to
rule out infection or the development of
agranulocytosis.

In the presence of high fever, the rare possibility of neuroleptic malignant syndrome (NMS) should be considered.
Pulse >120 bpm
or a rise in
heart rate >30 bpm		 Tachycardia is a common adverse effect from clozapine but can sometimes be linked to myocarditis, cardiomyopathy or NMS.

Consider whether etiology is due to hypovolaemia, or orthostasis due to effects of current medications.

Consider slower titration or dose reduction of clozapine.

If tachycardia persistent, observe for other indicators of myocarditis, cardiomyopathy or NMS.
Postural drop in blood pressure >30mmHg. Orthostasisis a common adverse effect from clozapine. Consider slower titration or dose reduction.
*Patient reports intolerable adverse effects e.g. excessive
sedation, weight gain,
constipation, etc.

Both the physical examination and the
history obtained prior to the exam provide important data.

For example, questions regarding symptoms of heart failure or constipation elicit information that could possibly be missed from vital signs, ECG or laboratory measures.

Smoking status and history of seizures must be noted.

Consider slower titration or dose reduction.

Adjunctive medication, eg, laxatives may be
indicated for constipation; metformin/ aripiprazole
to attenuate weight gain/ sedation.

In rare situations it may be necessary to hold clozapine initiation until adverse effect is resolved.

*The “GASS for Clozapine” or other recognised side-effect questionnaire for antipsychotic medication can be used during initiation and regularly thereafter.

Laboratory Monitoring

In addition to the physical monitoring undertaken during the initial titration, the following laboratory measures must be taken:

Day of titration Observations Action if outside reference range
Days 0, 7, 14, 21 and 28
  • Full blood count
  • CRP
  • Troponin I
  • Follow manufacturer’s mandatory protocol (see FBC monitoring schedule, above)

Myocarditis is an uncommon but potentially fatal complication of clozapine (reported rates 0.1 to 3.0%).

  • If: CRP 50 to 100 mg/L
    OR mild elevation of troponin I ≤2 x the upper limit of normal: Continue clozapine with daily CRP and troponin I monitoring and request echocardiography.
  • If: CRP >100mg/L OR troponin I >2 x upper limit of normal: Stop clozapine, consult a cardiologist and request echocardiogram
Days 0, 28
  • Fasting glucose
  • Offer lifestyle advice.
  • Obtain HbA1c.
  • Consult with GP and/or specialist as appropriate.
  • This monitoring for in-patients and Inverness out-patients is routinely undertaken at the Clozapine Clinic at New Craigs Treatment Centre. This runs every Monday morning on a drop-in basis.
  • Outwith the clozapine clinic, the sector doctor or duty doctor may be required to take clozapine bloods for these patients if the treatment centre  nurse is unavailable.
  • Arrangements must be in place for all other community initiation out-patients to have this monitoring carried out at an ITR or GP Practice.
  • All patients prescribed clozapine should have ongoing physical health monitoring according to the NHS Scotland Clozapine Physical Health Monitoring Standards irrespective of the care setting.

Therapeutic drug monitoring

Clozapine therapeutic drug monitoring can be useful in certain circumstances, but is not required for routine management, for example:

  • If the patient’s smoking status changes
  • To monitor compliance
  • In poor responders after an adequate trial, especially prior to consideration of augmentation strategies
  • If dose reduction is being contemplated
  • To diagnose dose-related side effects
  • If a drug interaction is suspected
  • Non-urgent investigation of suspected overdose
  • Measuring baseline levels during successful treatment to use as a reference point
  • For patients on long-term, high dose who have no evidence of previous levels being assessed

Requesting a plasma level

All blood samples for clozapine plasma levels should be sent direct to the Blood Sciences labs at Raigmore Hospital who then outsource the analysis to an external laboratory (Magnalabs).

  • A minimum of 2mL of venous blood is required to perform the assay.
  • A 10 to 14 hour trough sample should be taken
  • Use an EDTA (pink/red-topped) tube.
  • Please note that if an FBC is also required, TWO separate EDTA tubes will be necessary

Use the standard Area Laboratory Service Blood Sciences request form and request a Clozapine Plasma Level. An assay request form (available from the Magnalabs website) should also be completed in full with the following information:

  • Date of sample collection
  • Time of sample collection
  • Date of last clozapine dose
  • Time of last clozapine dose
  • Dose of clozapine
  • If smoker or non-smoker

Results are available on SCI-store, usually within a week of the sample being taken.

Interpretation of plasma levels

Therapeutic drug monitoring of clozapine is a useful tool in optimising dose, minimizing adverse effects and monitoring adherence but should always be used in conjunction with clinical observations.

Most studies indicate that a threshold for response is in the range 0.35 to 0.42 mg/L, however the threshold may be as high as 0.5mg/L.

The clozapine : norclozapine ratio may aid assessment of recent adherence. The ratio of clozapine to norclozapine differs between individuals, however, in chronic dosing, the ratio should remain the same for a given patient.

Clozapine : norclozapine Rationale
= 1.32 The expected average value for non-smokers
<1.32
  • Concurrent enzyme inducer
  • Or patient has an ultra rapid metaboliser status (CYP1A2 polymorphism)
  • Or possible poor adherence.
>1.32
  • Only partially adherent in the last few days
  • Or patient has a poor metaboliser status
  • Or true trough hasn't been taken
  • Or saturation of clozapine metabolism.

 

Re-titration following a treatment break

A patient is deemed to have had a clozapine treatment break if dosing has been interrupted for more than 48 hours.

If treatment has been missed for less than 48 hours this is not classed as a treatment break and dosing may resume without any adjustment.

Impact on dosing

  • Re-starting clozapine after gaps of various lengths should take account of the need to regain antipsychotic activity with clozapine while ensuring safety during titration.
  • Depending on tolerability, it may be feasible to re-titrate the dose to a therapeutic level more rapidly than is recommended for initial treatment.
  • More cautious dosage titration may be appropriate for certain patients, such as patients who experienced adverse effects (eg, postural hypotension, persistent tachycardia), during initial titration, patients who are elderly, patients with Parkinson’s disease, and for those re-titrating in a community setting.

The dosage schedule prescribed for a patient will depend upon how previous dosages were tolerated.

  • Patients should recommence clozapine treatment starting from 12.5mg, increasing to 25mg for the next dose, if the initial dose causes no adverse problems with, for example, sedation, heart rate or blood pressure.
  • If the 25mg dose is well tolerated, then 50mg can be given for the next dose, and so on.
  • Twice daily dosing may be considered to allow for an optimum rate of titration.
  • Where a given dose in the titration schedule is not tolerated, the next dose should usually be delayed, not increased and possibly decreased.

The following factors should be considered when deciding how quickly to increase the dose:

  • Previous dose and length of time at that dose. The higher the dose the longer re-titration will take.
  • Length of treatment break.
  • Tolerability of original dose titration (e.g. any evidence of postural hypotension, persistent tachycardia).
  • Age of patient and any co-morbidity that may increase risk of adverse effects.
  • Reason for the treatment break (eg, intolerable dose-related side effects, physical illness).
  • Change in smoking status, which may have an impact on the target dose.
  • The setting in which the re-titration will take place.
    Hospital re-titrations may allow more rapid dose escalation as more intense monitoring is possible.
    Patients may be discharged prior to the completion of their re-titration if the CMHT can support the necessary monitoring.
  • If there are tolerability issues during the re-titration e.g. tachycardia, blood pressure changes, sedation, then the rate of titration can be slowed.

If in doubt, follow the standard initiation titration above.

Impact on full blood count monitoring

Previous monitoring frequency Time elapsed since last dose New monitoring frequency
Weekly <3 days Continue weekly as before
>3 days Weekly for next 18 weeks
Fortnightly <3 days Fortnightly
>3 days but <4 weeks Weekly for 6 weeks, then fortnightly
>4 weeks Treat as new patient
Monthly <3 days Monthly
>3 days but <4 weeks Weekly for 6 weeks, then monthly
>4 weeks Treat as new patient


The clinical team must notify New Craigs Pharmacy of the treatment break as soon as possible who will in turn notify the clozapine monitoring service, even if clozapine treatment has already been resumed.

Please note: Patients must have a valid full blood count result in place before restarting clozapine.

Patient information

The Choice and Medication website includes a variety of patient information leaflets (in a variety of formats and languages), handy fact sheets and handy charts that can be used to provide written information to support the discussion about the risks and benefits of clozapine treatment.

All new patients for whom clozapine treatment is being considered will be given appropriate information about the risks, benefits, and any alternative treatments, to allow them to make an informed choice. 

Where patients lack capacity, or are to receive compulsory treatment under Part 16 of the Mental Health (Care and Treatment) (Scotland) Act 2003 where a T2 or T3 form is required to authorise such treatment, information will be provided commensurate to their needs and capability.

The information needs of patients will vary over time and often need to be tailored to their capacity and mental state at different stages of their illness.

Information for patients will cover:

  • Indication
  • How long treatment is likely to last
  • The need and rationale for regular blood tests (explaining red, amber, green results) and physical
    health checks
  • How to take clozapine, including compliance advice and what to do in the event of missed doses
  • How prescriptions will be provided
  • Very common and common side effects and what to do about them, with a particular focus on
    constipation, sedation, hypersalivation, weight gain and urinary incontinence
  • Where appropriate, the likelihood of developing some of the more serious risks, like cardiac problems, diabetes and seizures will be discussed in the context of enhanced monitoring
  • What to do in the event of developing signs of infection, eg, sore throat, fever, flu-like symptoms
  • Significant interactions, especially alcohol and smoking
  • Family planning and pregnancy, where appropriate

References

  • BARNES, T.R.E. et al., 2011. Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 0(0) 1–54 2011 [online] via https://www.bap.org.uk/pdfs/BAP_Guidelines-Schizophrenia.pdf
  • BAZIRE, S. (2020) Psychotropic drug directory 2020/21: the professionals’ pocket handbook and aide memoire. Stratford upon Avon: Lloyd-Reinhold Publications Ltd.
  • ELECTRONIC MEDICINES COMPENDIUM (EMC) Clozaril, Denzapine and Zaponex SmPCs[online] via
    https://www.medicines.org
  • MEYER J.M., STAHL S.M., The Clozapine Handbook. Cambridge University Press. Oct 2021 [online] (subscription required) via 
  • NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE), 2014. Clinical Guideline 178: Psychosis and schizophrenia in adults: prevention and management. London: National Institute for Health and Clinical Excellence. [online]. via https://www.nice.org.uk/guidance/cg178/resources/psychosis-and-schizophrenia-in-adults-prevention-and-management-pdf-35109758952133
  • NHS 24. Choice and Medication. [online]. Mistura Enterprise Ltd. [online] via https://www.choiceandmedication.org/nhs24
  • SCOTTISH GOVERNMENT SGHD/CMO (2017)4 National standard for monitoring the physical health of people being treated with clozapine. [online] via https://www.sehd.scot.nhs.uk/cmo/CMO(2017)04.pdf
  • TAYLOR, D. M., et al., (2021). The Maudsley prescribing guidelines in psychiatry (14th ed.). John Wiley & Sons.
  • WESTMEAD MENTAL HEALTH SERVICES (2012). Mental health Assessment Tools.2nd edition [online] Laois Offaly Longford via https://www.drugsandalcohol.ie/17625/1/MentalHealthAssessmentTools.pdf

ABBREVIATIONS

 

Abbreviation  Meaning 
ANC Absolute neutrophil count
CGI-SGH  clinical global impression - Schizophrenia scale 
CRP  C-reactive protein
ECG  Electrocardiogram
FBC  Full blood count
GASS  Glasgow Antipsychotic Side-effects Scale 
ITR  Investigation and Treatment Room 
LFTs  Liver function tests
MHRA  Medicines & Healthcare Products Regulatory Agency
mKGV  Modified Krawieka Goldberg and Vaughan Psychiatric Assessment scale
PANSS  Positive and negative syndrome scale
U&Es  Urine and electrolytes

 

Editorial Information

Last reviewed: 29/02/2024

Next review date: 31/12/2026

Author(s): Mental Health Clinical Governance Group.

Version: 1

Approved By: TAMSG of the ADTC

Reviewer name(s): Karen Macaskill, Principal Pharmacist, Mental Health.

Document Id: TAM625

References

Patient information