Is there only one best titration standard for starting clozapine?

A plan for the titration of clozapine should be specific to a person’s needs based on a number of factors. This includes age, gender, smoking status, other medications, race/ethnicity, and clinical urgency. Published samples for inpatient titrations are generally faster than outpatient ones. Slower titrations may be less likely to result in clozapine-induced myocarditis. Slower titrations may also help avoid settling on a dose that is too high for a person or preventing someone from stopping the medication early. Prescribers need to be flexible when they conduct new clozapine titrations. They may need to adjust the plan as the titration continues.

Learn more about common myths around clozapine. See our infographic on this topic.

ACCESS RESOURCE

 

REFERENCES

  • American Psychiatric Association. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia, Third Edition 2020 [9/24/2020]. Available from: https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
  • Chan S., Chan H., Honer W., Bastiampillai T., Suen Y., Yeung W., et al. (2021). Predictors of Treatment-Resistant and Clozapine-Resistant Schizophrenia: A 12-Year Follow-up Study of First-Episode Schizophrenia-Spectrum Disorders. Schizophrenia Bulletin, 47(2):485-94.
  • Yoshimura B., Yada Y., So R., Takaki M., Yamada N. (2017).The critical treatment window of clozapine in treatment-resistant schizophrenia: Secondary analysis of an observational study. Psychiatry Research, 250:65-70.
  • Cotes R., Janjua A., Broussard B., Lazris D., Khan A., Jiao Y., et al. (2021). A Comparison of Attitudes, Comfort, and Knowledge of Clozapine Among Two Diverse Samples of US Psychiatrists. Community Ment Health J, 58(3):517-525. doi: 10.1007/s10597-021-00847-0.
  • Schoretsanitis G., Kane J., Correll C., Marder S., Citrome L., Newcomer J., et al. (2020). Blood Levels to Optimize Antipsychotic Treatment in Clinical Practice: A Joint Consensus Statement of the American Society of Clinical Psychopharmacology and the Therapeutic Drug Monitoring Task Force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie. J Clin Psychiatry, 81(3):19cs13169. doi: 10.4088/JCP.19cs13169.
  • Northwood K., Pearson E., Arnautovska U., Kisely S., Pawar M., Sharma M., et al. (2023). Optimising plasma clozapine levels to improve treatment response: an individual patient data meta-analysis and receiver operating characteristic curve analysis. British J Psychiatry, 222(6):241-5. doi: 10.1192/bjp.2023.27.
  • Rostami-Hodjegan A., Amin A., Spencer E., Lennard M., Tucker G., Flanagan R. (2004). Inuence of dose, cigarette smoking, age, sex, and metabolic activity on plasma clozapine concentrations: a predictive model and nomograms to aid clozapine dose adjustment and to assess compliance in individual patients. J Clin Psychopharmacol, 24(1):70-8. doi: 10.1097/01.jcp.0000106221.36344.4d.
  • Manu P., Sarvaiya N., Rogozea L., Kane J., Correll C. (2016). Benign Ethnic Neutropenia and Clozapine Use: A Systematic Review of the Evidence and Treatment Recommendations. J Clin Psychiatry, 77(7):e909-16.
  • Cotes R. (2023). Are slow clozapine titrations safer than fast ones? Poster Presentation at the Schizophrenia International Research Society Annual Congress.
  • Cotes R., Goldsmith D. (2022). The Tortoise Beats the Hare: The Case for Slow Clozapine Titrations with Serial CRP Monitoring. Psychiatria Danubina, 34(3):428-9.
  • Ronaldson K., Fitzgerald P., Taylor A., Topliss D., Wolfe R., McNeil J. (2012). Rapid clozapine dose titration and concomitant sodium valproate increase the risk of myocarditis with clozapine: a case-control study. Schizophr Res, 141(2-3):173-8.
  • Was this Helpful ?
  • YesNo

Join our #MissionForBetter now

Sign up for our newsletter. We’ll let you know about new resources, education, and more.

X