see also: [[schizophrenia]] see: [Hayes' Clozapine](x-devonthink-item://E78534E8-BE8A-4488-8929-0F4748813A24) and [Clozapine toxicity](x-devonthink-item://D0EEA2F1-9A35-4B7D-89C6-03F92BE53DE6) [Austin Clozapine overdose](x-devonthink-item://DEDB277A-CCF2-4A4B-ADF6-1F68F5EB9338) > [!info] > Category: `=this.Category` > risk of *agranulocytosis*, neutropenia, myocarditis > ## Overview - 2nd generation atypical antipsychotic - **4 life threatening reactions:** - [[febrile neutropenia|neutropenia]] - [[Myocarditis]] / cardiomyopathy - [[Neuroleptic Malignant Syndrome|NMS]] - lowered [[Seizures]] threshold Dose: tablets in 25mg - 200mg > another serious issue is clozapine-associated [[#Clozapine Induced Gastrointestinal Hypomotility (CIGH)|constipation]], which can lead to bowel obstruction **Key points** - treat clozapine patients with fever as [[febrile neutropenia]] patient - in pts with persistent tachycardia at rest with other signs of heart failre, consider myocarditis or cardiomyopathy - risks of NMS not as high as first gen antipsychotics - rare to cause extrapyrmadil effects can also cause: - eosinophilia → discontinue if eosinophil count >3,000 mm3 - thrombocytopenia → cease if plts <50 - [[Anticholinergic toxicity|anticholinergic effects]] - macular degeneration (very rare) ## Clozapine Induced Gastrointestinal Hypomotility (CIGH) CIGH can result in severe constipation leading to bowel obstruction, toxic megacolon, paralytic ileus, intestinal perforation or ischaemia which can be life threatening Serious CIGH effects are a medical emergency 1. Symptoms of constipation can include bloating, straining, hard stools, abdominal discomfort or distention, a feeling of incomplete evacuation after a bowel movement, infrequent bowel movement, 2. Commence treatment with aperients if constipation present ==and there is no evidence of ileus.== Consider the treatment recommendation below: > - Start docusate with senna 50mg/8mg 2 tablets orally at night > - If constipation remains after 48 hours increase the dose of docusate with senna to 4 tablets orally at night > - If constipation remains after further 48 hours, commence macrogol 3350 with electrolytes (e.g. Movicol) 1 sachet orally twice a day, perform digital rectal examination with chaperone and and abdominal X-ray and consult with a gastroenterologist or colorectal surgeon or refer to an Emergency Department or Urgent Care Centre > - If obstruction develops, then refer immediately to nearest Emergency Department for assessment of need for colorectal surgery. > - If diarrhoea develops after any step, gradually reduce and/or discontinue recently added treatments. > - Avoid use of bulk forming laxatives such as psyllium (e.g. Metamucil) or fibre supplements Rechallenging following ileus: - Obtain an opinion from the colorectal surgeon and/or gastroenterologist about appropriate aperient regimen. - Consult psych and titrate clozapine very slowly (e.g. 6.25mg every three days)