Clozapine usage in a public sector psychiatric hospital in the Nelson Mandela Metropole

Abstract

About 30.00% of schizophrenic patients fail to respond to conventional antipsychotics. Clozapine shows superior efficacy, for both the positive and negative symptoms of schizophrenia, over conventional antipsychotics. The reputation of clozapine lies mainly with its repeated proven efficacy in the treatment of refractory schizophrenia. However, clozapine has quite a severe side effect profile. Patients receiving clozapine therapy may develop serious adverse effects such as agranulocytosis, neutropenia and metabolic syndrome. Therefore guidelines are required which recommend that regular haematological and metabolic monitoring be performed. These monitoring guidelines should assist medical practitioners in the early detection and reporting of serious adverse effects associated with clozapine therapy. South Africa lacks uniform provincial or national guidelines regulating practices in the treatment of mental disorders. International guidelines may be considered, which are not specifically adapted for the South African setting. These guidelines recommend both the haematological and metabolic monitoring of clozapine. At present there are no South African guidelines recommending the metabolic monitoring of clozapine. The general aim of the study was to determine the prescribing and monitoring patterns of clozapine at Elizabeth Donkin Hospital in the Nelson Mandela Metropole. Due to the absence of specific South African guidelines and the severe side effect profile of clozapine, some of the research objectives were to determine whether the initiation of clozapine, as well as the haematological and metabolic monitoring performed, was compliant with international clinical guidelines. In this pharmacoepidemiological study a retrospective drug utilisation review was performed. The study was observational in design and included quantitative data. Data were collected from the files of 65 patients (N=65) discharged on clozapine between 1 December 2010 and 29 February 2012. Follow-up investigations were performed at the clinics and long-term care centres both three months and six months after discharge. In 52.30% (n=34) of the cases clozapine was previously prescribed. Compliance with the National Institute for Health and Clinical Excellence (NICE) guidelines for the appropriate initiation of clozapine was 63.10% (n=41). Compliance with the Standard Treatment guidelines for the initiation of clozapine by a psychiatrist was 63.10% (n=41). Noncompliance with the recommended guidelines for haematological monitoring occurred in 77.40% of patients in the hospital setting (n=48) as well as in 95.70% of patients during the three-month follow-up at the clinics (n=44). Non-compliance with the guidelines for metabolic monitoring occurred in all the observed patients in the hospital setting (n=62) as well as in 45.70% of patients in the clinic setting (n=21). It was found that 71.00% (n=46) of patients were still on clozapine three months after discharge and 65.00% (n=42) were still on clozapine six months after discharge from hospital, resulting in discontinuation rates of 29.00% and 35.00% respectively. It was found that clozapine was inadequately monitored although in most cases the initiation of clozapine was compliant with the recommended guidelines. However, practitioners should be trained on the existing prescribing and monitoring guidelines to promote the rational use of clozapine in the public health sector of South Africa.