What should be considered regarding concurrent psychiatric medications, medications a patient is taking while considering or starting clozapine?

Patients who are considering starting clozapine are often taking multiple psychiatric medications. This occurs often because none of the medications is very effective. In general, a goal is to taper off most or all of these medications at some point during clozapine treatment, since they often add little or no efficacy. Other antipsychotic medications can often be tapered off once clozapine is sufficiently effective. Carbamazepine should be avoided while taking clozapine, since it has potential effects on white blood cells. It should be tapered off before clozapine or very soon after starting clozapine. Patients are often on sedative or calming medications before clozapine, such as benzodiazepines, valproate, gabapentin, and similar medications. These should be tapered to the extent possible before clozapine, then tapered further and stopped as sedation and calming from clozapine emerges. There can be risk due to additive sedative effects, particularly for benzodiazepines, so the use these should be the minimum necessary. Sleeping medications are typically not needed due to the sedation of clozapine taken at bedtime, and can be stopped. Medications of limited effectiveness in psychotic disorders, such as antidepressant medications, can often be tapered off before clozapine or early in clozapine titration. Antipsychotic medications are often continued during a clozapine start until clozapine becomes sufficiently effective against psychotic symptoms, which can take time, until a therapeutic dosage is reached.

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