Is it possible to plan for continuation of clozapine during emergencies (such as coronavirus COVID-19 pandemic, infectious disease, hurricanes, tornadoes, earthquakes, rioting) that destroy infrastructure or limit travel, or other issues that prevent a patient from coming to a clinic or laboratory for necessary assessments or blood monitoring?

The COVID-19 pandemic reminds clinicians that there are circumstances that make clinical care more challenging. It may be possible to plan for such situations, to maintain continuity of treatment with clozapine.

First is to consider whether the patient is appropriate for the creation of an extra clozapine supply. This can be challenging as insurers are unlikely to pay for an extra supply of medication, but even having a 1-week cushion may prevent debilitating cholinergic rebound and psychosis from abrupt clozapine discontinuation. If the patient or family caregiver can afford it, one option is to provide a prescription for one week of medication, which may have to be purchased with cash if insurance will not cover the cost. At present, the outpatient full retail cost of generic clozapine is approximately 3.5 cents per mg. Thus, for someone on 400 mg/d, a one-week supply (2800 mg total) would be $98. There may also be tablets left over during dose changes or titrations, which can also be set aside for future emergency use.

Access to point-of-care (POC) ANC testing: There is an FDA approved device (Athelas) for POC ANC testing that is available in some locations. This system sends the results from a finger stick automatically to REMS, and delivers medication directly to the patient’s residence, medical office or residential office.  This device can be deployed in any care setting, and this may allow it to be used in licensed residential facilities thus obviating the need for the patient to go to an outside lab for ANC monitoring. If the device is at a mental health clinic, the patient now has two options for ANC testing: the clinic, or, if the clinic is not accessible, an outside lab using the usual prescription for a CBC with ANC.

Plan for remote follow-up: Whether due to patient or caregiver illness, or inability to travel for any reason, there should be a plan for follow-up, especially in patients who are beginning their clozapine treatment and who need closer attention. This plan can take into account patient access to a smartphone or computer, and the ability to use these devices. One always must be mindful of information security when using any telepsychiatry method, but in emergencies, one might document that the need to see the patient for assessment is critical, given limitations of available technology. For more stable patients a phone call may be sufficient. In all circumstances, one should note in the record the method used, and the information gleaned from the clinical encounter.

Also, the U.S. FDA has the authority to change guidance during major crises.

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