Why is clozapine not the first medication chosen to treat schizophrenia for everyone?

Clozapine is FDA-indicated for treatment-resistant schizophrenia and suicide prevention in patients with schizophrenia or schizoaffective disorder with chronic suicidal behaviors. Although clinical efficacy is superior to other second generation antipsychotic (SGA) medications, the side effect profile brings risks of agranulocytosis/neutropenia, seizure, cardiovascular issues (myocarditis, cardiomyopathy, mitral valve incompetence, QT prolongation, arrhythmias, torsades de pointes, CVA, syncope) in addition to the SGA class side effects (e.g., metabolic side effects, EPS).

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