Clozapine — consultant viva

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect TRRIP language, named trials, and automatic safety protocols without inventing one country's exact ANC cut-offs as universal law.[1][8]

Core questions and model points

1. When is clozapine indicated? TRS after two adequate adherent trials (TRRIP); high suicide risk schizophrenia (InterSePT). Kane principle of superiority in TRS. Siskind: offer earlier because response rates are meaningful.[1][2][3][8]

2. How do you start safely? Baseline bloods/metabolic/ECG/cardiac markers per protocol; start 12.5 mg; slow titration; weekly haematology early per local registry; first-month myocarditis vigilance.[4]

3. Week-3 fever and tachycardia? Myocarditis until proven otherwise — stop clozapine, ECG, CRP, troponin, cardiology. Risk amplifiers: rapid titration, valproate.[4]

4. Smoking cessation on the ward? CYP1A2 induction falls; levels rise; reduce dose and monitor levels/toxicity.[6]

5. Constipation? CIGH can kill; prevent from day one; escalate ileus as surgical emergency and stop clozapine.[5]

6. Five days missed? Re-titrate from low dose per product guidance — do not resume full maintenance immediately.[6]

7. Rechallenge after neutropenia? Specialist, reaction-specific; Manu-type case-series guidance; not automatic; haematology partnership.[7]

Pass criteria

• TRRIP and Kane/InterSePT/Siskind one-liners correct.[1][2][3][8]
• Myocarditis and CIGH recognised as stop-and-escalate emergencies.[4][5]
• Smoking/CYP1A2 and missed-dose re-titration automatic in speech.[6]
• Region-aware haematology principles without fabricated universal cut-offs.[1]