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Psychiatry
Clinical Pharmacology

Clozapine

High EvidenceUpdated: 2025-12-24

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Red Flags

  • Agranulocytosis (neutropenia <1.5×10⁹/L)
  • Myocarditis (chest pain, tachycardia, fever, raised troponin)
  • Cardiomyopathy
  • Severe constipation leading to ileus/bowel obstruction
  • Seizures
  • Neuroleptic malignant syndrome
Overview

Clozapine

1. Clinical Overview

Summary

Clozapine is an atypical (second-generation) antipsychotic that is the most effective treatment for treatment-resistant schizophrenia (TRS). It is reserved for patients who have failed at least two other antipsychotics at adequate doses for adequate duration. Clozapine reduces positive symptoms, negative symptoms, and importantly reduces suicidality in schizophrenia. However, it has significant side effects requiring mandatory monitoring, most notably agranulocytosis (~1%), which is potentially fatal. Other serious complications include myocarditis, cardiomyopathy, severe constipation (leading to ileus), and seizures. Clozapine is only available through a registered monitoring service (CPMS in UK). Patients require regular blood tests: weekly for the first 18 weeks, then fortnightly for up to 1 year, then monthly thereafter.

Key Facts

  • Indication: Treatment-resistant schizophrenia (failed 2 antipsychotics)
  • Efficacy: Most effective antipsychotic; reduces suicidality
  • Mechanism: Weak D2 antagonist; strong 5-HT2A antagonist; binds D4, H1, M1, α1
  • Agranulocytosis: ~1% risk; requires mandatory FBC monitoring
  • Monitoring: Weekly (18 weeks) → Fortnightly (52 weeks) → Monthly (lifelong)
  • Myocarditis: Usually within first month; can be fatal; monitor troponin/CRP
  • Constipation: Potentially fatal (ileus); anticipate and treat proactively
  • Sialorrhoea: Common (hypersalivation); treat with hyoscine or glycopyrrolate
  • Re-titration: Required if >48 hours missed (risk of hypotension, collapse)
  • Traffic light system: Green/Amber/Red for neutrophil count

Clinical Pearls

"Clozapine Is the Most Effective Antipsychotic": For treatment-resistant schizophrenia, clozapine is uniquely effective. It's also the only antipsychotic proven to reduce suicide risk (InterSePT trial).

"Traffic Light = Life or Death": The Green/Amber/Red monitoring system is mandatory. Red means STOP immediately — agranulocytosis is fatal without intervention.

"Myocarditis in the First Month": Clozapine-induced myocarditis usually occurs within 4 weeks. Monitor for tachycardia, fever, chest pain. Check troponin, CRP, and ECG. Fatal if missed.

"Constipation Can Kill": Clozapine causes severe constipation due to anticholinergic effects. Ileus and bowel obstruction are major causes of death. Proactive laxatives are essential.

"48-Hour Rule": If clozapine is missed for >48 hours, re-titration from a low dose is mandatory. Rapid reinitiation can cause severe hypotension or cardiac arrest.

Why This Matters Clinically

Clozapine is a life-changing medication for patients with TRS but requires meticulous monitoring. Every clinician prescribing or caring for patients on clozapine must understand the monitoring protocols, recognise side effects, and know when to stop treatment. The UK CPMS (Clozapine Patient Monitoring Service) is mandatory.[1,2]


2. Epidemiology

Use in Clinical Practice

ParameterData
Patients on clozapine (UK)~45,000
Treatment-resistant schizophrenia prevalence~30% of schizophrenia patients
Time to clozapine initiationOften delayed; 4-5 years after diagnosis on average
UnderprescriptionClozapine is underused despite being most effective

Risk Factors for Agranulocytosis

FactorNotes
AgeHigher risk in elderly
SexFemales at higher risk
EthnicityBenign ethnic neutropenia (BEN) in Black patients may complicate monitoring
Concurrent medicationsRisk with other bone marrow suppressants
First 18 weeksHighest risk period

3. Pathophysiology

Mechanism of Action

Receptor Pharmacology:

ReceptorActionClinical Effect
D2 (dopamine)Weak antagonistLess EPS than typical antipsychotics
5-HT2A (serotonin)AntagonistEfficacy for negative symptoms; less EPS
D4 (dopamine)AntagonistMay contribute to efficacy
H1 (histamine)AntagonistSedation, weight gain
M1 (muscarinic)AntagonistConstipation, dry mouth, sialorrhoea (paradoxically)
α1 (adrenergic)AntagonistHypotension, sedation

Why Clozapine Works in TRS

  • Unique receptor binding profile (multi-receptor)
  • Higher 5-HT2A:D2 ratio than other antipsychotics
  • Effects on glutamatergic system (NMDA modulation)
  • Fast dissociation from D2 receptors ("fast-off" hypothesis)
  • Effects on neural plasticity

Agranulocytosis Mechanism

FeatureDetails
MechanismImmune-mediated (antibodies to neutrophils) or direct toxicity
MetaboliteNorclozapine may be responsible
TimingUsually within first 18 weeks; can occur later
Incidence~1% (higher than other drugs)
Mortality~3% if untreated; now <0.1% with monitoring

4. Clinical Presentation

Indications for Clozapine

Treatment-Resistant Schizophrenia (TRS):

CriteriaDetails
DefinitionFailed adequate trials of ≥2 antipsychotics
Adequate trialAt least 6 weeks at therapeutic dose with ≥80% adherence
IncludesAt least one atypical (second-generation) antipsychotic
DocumentationMust document non-response to previous treatments

Other Uses (Off-label/Specialist):

Clinical Features Requiring Clozapine

FeatureNotes
Persistent positive symptomsHallucinations, delusions despite treatment
Cognitive symptomsMay improve on clozapine
Negative symptomsMay improve
SuicidalityClozapine uniquely reduces suicide risk
Violence/aggressionOften responds

Severe aggression or violence in schizophrenia
Common presentation.
Suicidality in schizophrenia
Common presentation.
Schizoaffective disorder
Common presentation.
Psychosis in Parkinson's disease (low doses)
Common presentation.
5. Clinical Examination

Baseline Assessment Before Clozapine

AssessmentPurpose
Full physical examinationBaseline health; cardiorespiratory status
CardiovascularBP, HR; ECG (exclude arrhythmia, prolonged QTc)
BMIBaseline weight
Bowel habitDocument baseline; constipation is major issue
NeurologicalExclude movement disorders from previous antipsychotics

Ongoing Monitoring Parameters

ParameterFrequencyThreshold
FBC (neutrophils)Weekly (18 wks), Fortnightly (52 wks), MonthlyGreen/Amber/Red
WeightMonthlyTrack metabolic effects
Blood glucoseBaseline, 1 month, then 4-6 monthlyDiabetes risk
LipidsBaseline, 3 months, then annuallyMetabolic syndrome
ECGBaselineQTc prolongation
Troponin/CRPIf myocarditis suspectedMyocarditis screen
Bowel functionEvery consultationConstipation screening

6. Investigations

Mandatory Blood Monitoring

Traffic Light System for Neutrophils:

StatusNeutrophil CountAction
🟢 GREEN≥2.0×10⁹/LContinue clozapine; routine monitoring
🟡 AMBER1.5-1.99×10⁹/LIncreased monitoring (2x weekly); watch closely
🔴 RED<1.5×10⁹/LSTOP CLOZAPINE IMMEDIATELY; never rechallenge

Benign Ethnic Neutropenia (BEN)

FeatureDetails
DefinitionLower baseline neutrophil counts in some individuals (especially Black African/Caribbean)
AdjustmentModified thresholds may be used (Green ≥1.5; Amber 1.0-1.49; Red <1.0)
RequiresHaematologist confirmation before modified monitoring

Investigations for Complications

ComplicationInvestigations
MyocarditisTroponin, CRP, ECG, Echocardiogram
CardiomyopathyEchocardiogram, BNP
Ileus/bowel obstructionAbdominal X-ray, CT
SeizuresEEG; consider levels; dose adjustment

7. Management

Management Algorithm

              CLOZAPINE PRESCRIBING PATHWAY
                         ↓
┌─────────────────────────────────────────────────────────────┐
│                PRE-TREATMENT ASSESSMENT                      │
├─────────────────────────────────────────────────────────────┤
│  ➤ Confirm diagnosis of schizophrenia (ICD/DSM criteria)   │
│  ➤ Document failure of ≥2 antipsychotics at adequate       │
│    dose/duration                                            │
│  ➤ Baseline investigations:                                 │
│    • FBC (neutrophils ≥2.0)                                 │
│    • U&E, LFTs                                              │
│    • Fasting glucose, lipids                                │
│    • ECG (QTc)                                              │
│    • Weight, BMI                                            │
│    • Document bowel habit                                   │
│  ➤ Register with Clozapine Monitoring Service (CPMS)       │
└─────────────────────────────────────────────────────────────┘
                         ↓
┌─────────────────────────────────────────────────────────────┐
│                    INITIATION                                │
├─────────────────────────────────────────────────────────────┤
│  DAY 1: 12.5 mg once or twice daily                         │
│  Increase gradually over 2-3 weeks:                         │
│  ➤ 12.5-25 mg increments every 1-2 days                    │
│  ➤ Target dose: 200-450 mg/day (divided doses)             │
│  ➤ Maximum: 900 mg/day (rarely used)                       │
│                                                              │
│  INPATIENT vs OUTPATIENT:                                    │
│  ➤ Inpatient initiation traditionally preferred            │
│  ➤ Outpatient initiation possible with MDT support         │
│                                                              │
│  MONITORING DURING INITIATION:                               │
│  ➤ BP, HR (postural hypotension risk)                       │
│  ➤ Temperature (fever = myocarditis concern)               │
│  ➤ Weekly FBC (CPMS)                                        │
└─────────────────────────────────────────────────────────────┘
                         ↓
┌─────────────────────────────────────────────────────────────┐
│              ONGOING MONITORING (CPMS)                       │
├─────────────────────────────────────────────────────────────┤
│  BLOOD MONITORING SCHEDULE:                                   │
│  ➤ Weeks 1-18: Weekly FBC                                   │
│  ➤ Weeks 19-52: Fortnightly FBC                             │
│  ➤ After 52 weeks: Monthly FBC (lifelong)                   │
│                                                              │
│  TRAFFIC LIGHT RESULTS:                                       │
│  🟢 GREEN (≥2.0): Continue clozapine                        │
│  🟡 AMBER (1.5-1.99): Monitor 2x weekly; liaise with CPMS   │
│  🔴 RED (&lt;1.5): STOP IMMEDIATELY; never rechallenge         │
│                                                              │
│  OTHER MONITORING:                                           │
│  ➤ Metabolic (glucose, lipids): 3-6 monthly                │
│  ➤ Weight: Monthly                                          │
│  ➤ Bowel function: Every review                            │
│  ➤ Clozapine levels: If suboptimal response, toxicity,     │
│    or smoking change                                         │
└─────────────────────────────────────────────────────────────┘
                         ↓
┌─────────────────────────────────────────────────────────────┐
│             MANAGING SIDE EFFECTS                            │
├─────────────────────────────────────────────────────────────┤
│  CONSTIPATION:                                               │
│  ➤ Proactive laxatives (docusate, senna, macrogol)         │
│  ➤ Ask about bowel function at EVERY review                │
│  ➤ If severe: Abdominal X-ray; gastroenterology referral   │
│  ⚠️ Ileus is a FATAL complication                           │
│                                                              │
│  SIALORRHOEA (hypersalivation):                             │
│  ➤ Hyoscine hydrobromide patches                            │
│  ➤ Glycopyrrolate                                           │
│  ➤ Nighttime worst; use absorbent pillows                  │
│                                                              │
│  SEDATION:                                                   │
│  ➤ Give larger dose at night                                │
│  ➤ Often improves with time                                 │
│                                                              │
│  WEIGHT GAIN / METABOLIC:                                   │
│  ➤ Diet and exercise counselling                           │
│  ➤ Consider metformin adjunct                              │
│                                                              │
│  TACHYCARDIA:                                                │
│  ➤ Common initially (may resolve)                           │
│  ➤ If persistent + fever + malaise: exclude myocarditis    │
│                                                              │
│  SEIZURES:                                                   │
│  ➤ Risk increases with dose (&gt;600 mg/day)                  │
│  ➤ Add sodium valproate prophylaxis if high-dose           │
└─────────────────────────────────────────────────────────────┘
                         ↓
┌─────────────────────────────────────────────────────────────┐
│              MISSED DOSES / RE-TITRATION                     │
├─────────────────────────────────────────────────────────────┤
│  IF MISSED &gt;48 HOURS:                                        │
│  ➤ DO NOT resume at previous dose                           │
│  ➤ Re-titrate from 12.5-25 mg                              │
│  ⚠️ Rapid reinitiation → severe hypotension, collapse       │
│                                                              │
│  IF MISSED &gt;3 DAYS:                                          │
│  ➤ Full re-titration as per initiation protocol            │
│  ➤ Resume weekly FBC monitoring                            │
└─────────────────────────────────────────────────────────────┘

Clozapine Levels

LevelInterpretation
<350 ng/mLPossibly subtherapeutic
350-600 ng/mLTherapeutic range
>1000 ng/mLToxicity risk

Factors affecting levels:

  • Smoking (induces CYP1A2 → lowers levels)
  • Caffeine (inhibits CYP1A2 → raises levels)
  • Infections (transiently raise levels)
  • Concurrent medications

8. Complications

Agranulocytosis

FeatureDetails
DefinitionNeutrophils <0.5×10⁹/L
Incidence~1%
TimingUsually first 18 weeks
SymptomsFever, sore throat, infections
ActionSTOP clozapine; admit; haematology; G-CSF
OutcomeUsually reversible if caught early
RechallengeNEVER — lifetime contraindication

Myocarditis and Cardiomyopathy

FeatureMyocarditisCardiomyopathy
TimingUsually first 4 weeksCan occur later
SymptomsFever, tachycardia, chest pain, fatigueHeart failure symptoms
InvestigationsTroponin, CRP, ECG, EchoEcho, BNP
ManagementSTOP clozapine; cardiology; supportiveDepends on severity
RechallengeUsually contraindicatedCase-by-case

Constipation and Ileus

SeverityFeaturesManagement
MildInfrequent bowel movementsIncrease laxatives
ModerateStraining, hard stoolsCombination laxatives
SevereAbdominal distension, painAXR; surgical review
IleusBowel obstruction; surgical emergencySTOP clozapine; surgery

9. Prognosis & Outcomes

Efficacy Outcomes

OutcomeData
Response rate in TRS~30-60% respond to clozapine
SuperioritySuperior to all other antipsychotics in TRS
Suicide reduction25% reduction in suicidality (InterSePT)
Time to responseMay take 6-12 months for full effect

Long-Term Outcomes

FactorImpact
Continued useImproves functioning, quality of life
DiscontinuationHigh relapse risk
Metabolic effectsRequire ongoing management
MortalityReduced suicide; increased metabolic risk

10. Evidence & Guidelines

Key Guidelines

GuidelineOrganisationYearKey Points
Maudsley Prescribing GuidelinesSLaM2021Comprehensive clozapine guidance
NICE Schizophrenia (CG178)NICE2014Clozapine for TRS after 2 failures
BAP Schizophrenia GuidelinesBAP2020Evidence-based prescribing

Landmark Trials

InterSePT Trial (2003)

  • Clozapine vs olanzapine for suicidal schizophrenia patients
  • Clozapine reduced suicidal behaviour by 25%
  • Led to FDA approval for suicidality indication
  • PMID: 12505305

Kane et al. (1988)

  • Landmark RCT establishing clozapine for TRS
  • Clozapine superior to chlorpromazine in TRS
  • PMID: 3047143

11. Patient/Layperson Explanation

What is Clozapine?

Clozapine is a medication used to treat schizophrenia that hasn't responded to other medications. It's very effective, but requires regular blood tests because of potential side effects.

Why is it used?

Clozapine is used when at least two other antipsychotic medications haven't worked well enough. It can help control symptoms like hearing voices, paranoia, and disorganised thinking.

Why are blood tests needed?

Clozapine can rarely cause a serious drop in white blood cells (which fight infection). Regular blood tests check for this. You'll need blood tests:

  • Every week for the first 18 weeks
  • Every two weeks for the rest of the first year
  • Every month after that

Traffic light system

Your blood test result gives a colour:

  • Green: Everything is fine
  • Amber: Need more frequent tests
  • Red: Stop the medication immediately

What side effects might I notice?

  • Drowsiness — often improves over time
  • Drooling — especially at night
  • Constipation — very important to prevent; use laxatives
  • Weight gain — healthy diet and exercise help
  • Fast heartbeat — tell your doctor if this happens

Important things to remember

  • Never stop suddenly without talking to your doctor
  • If you miss doses for more than 2 days, you'll need to restart slowly
  • Tell your doctor if you feel unwell with a fever or sore throat

12. References

Guidelines

  1. Taylor DM, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. 14th ed. Wiley-Blackwell; 2021.

  2. NICE. Psychosis and schizophrenia in adults: prevention and management (CG178). 2014. nice.org.uk/guidance/cg178

Key Trials

  1. Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003;60(1):82-91. PMID: 12505305

  2. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry. 1988;45(9):789-796. PMID: 3047143


13. Examination Focus

High-Yield Exam Topics

TopicKey Points
IndicationTreatment-resistant schizophrenia (failed ≥2 antipsychotics)
Agranulocytosis~1% risk; mandatory FBC monitoring; never rechallenge if Red
Monitoring scheduleWeekly (18 wks) → Fortnightly (52 wks) → Monthly
MyocarditisFirst month; fever + tachycardia + raised troponin
ConstipationCan cause fatal ileus; proactive laxatives essential
48-hour ruleIf missed >48 hrs, re-titrate from low dose
InterSePT trialClozapine reduces suicidality

Sample Viva Questions

Q1: What are the indications for clozapine and how is it initiated?

Model Answer: Clozapine is indicated for treatment-resistant schizophrenia — defined as failure of at least two antipsychotics at adequate dose and duration (at least 6 weeks each). Before initiation: baseline FBC (neutrophils ≥2.0), ECG, metabolic screen, register with CPMS. Initiation: start at 12.5 mg once or twice daily, increase by 12.5-25 mg every 1-2 days. Target dose 200-450 mg/day. Inpatient initiation traditionally preferred but outpatient possible with support. Weekly FBC for first 18 weeks; watch for hypotension, tachycardia, fever (myocarditis).

Q2: A patient on clozapine has a neutrophil count of 1.3×10⁹/L. What do you do?

Model Answer: A neutrophil count of 1.3×10⁹/L is a RED result. I would STOP clozapine immediately and never rechallenge this patient. I would inform CPMS urgently, arrange repeat FBC, assess for signs of infection (fever, sore throat), and refer to haematology. Consider admission for monitoring. If neutropenia worsens, G-CSF may be required. The patient cannot be rechallenged with clozapine; alternative antipsychotics will be needed.

Q3: What are the life-threatening complications of clozapine?

Model Answer: The major life-threatening complications are:

  1. Agranulocytosis (~1%): Severe neutropenia; risk of overwhelming infection; usually first 18 weeks; requires immediate cessation.
  2. Myocarditis/Cardiomyopathy: Usually first month; presents with fever, tachycardia, chest pain; raised troponin; can be fatal.
  3. Ileus/Bowel obstruction: Severe constipation due to anticholinergic effects; can cause toxic megacolon and death. Proactive laxatives essential.
  4. Seizures: Risk increases with high doses (>600 mg); prophylactic valproate may be used.
  5. Pulmonary embolism: Higher risk in sedentary patients.

Common Exam Errors

ErrorCorrect Approach
Not knowing monitoring scheduleWeekly (18) → Fortnightly (52) → Monthly
Forgetting 48-hour ruleMust re-titrate if missed >48 hours
Thinking constipation is minorIt can be FATAL (ileus); proactive laxatives
Not mentioning CPMSMandatory registration in UK

Last Reviewed: 2025-12-24 | MedVellum Editorial Team


Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.

Last updated: 2025-12-24

At a Glance

EvidenceHigh
Last Updated2025-12-24

Red Flags

  • Agranulocytosis (neutropenia &lt;1.5×10⁹/L)
  • Myocarditis (chest pain, tachycardia, fever, raised troponin)
  • Cardiomyopathy
  • Severe constipation leading to ileus/bowel obstruction
  • Seizures
  • Neuroleptic malignant syndrome

Clinical Pearls

  • **"Traffic Light = Life or Death"**: The Green/Amber/Red monitoring system is mandatory. Red means STOP immediately — agranulocytosis is fatal without intervention.
  • **"Myocarditis in the First Month"**: Clozapine-induced myocarditis usually occurs within 4 weeks. Monitor for tachycardia, fever, chest pain. Check troponin, CRP, and ECG. Fatal if missed.
  • **"Constipation Can Kill"**: Clozapine causes severe constipation due to anticholinergic effects. Ileus and bowel obstruction are major causes of death. Proactive laxatives are essential.
  • **"48-Hour Rule"**: If clozapine is missed for &gt;48 hours, re-titration from a low dose is mandatory. Rapid reinitiation can cause severe hypotension or cardiac arrest.

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines