Despite the effectiveness of clozapine there remains a reluctance to use it because of concerns attributable to patient complexity and future adherence, physician comfort, the switching and initiating process, blood monitoring and the drug itself. Consequently, initiation of clozapine is frequently delayed and typically restricted to inpatient settings. Additional barriers to outpatient initiation include insufficient training for health care professionals (HCPs), reduced access to the patient for assessment, and infrastructure limitations.
In the absence of any practice guidelines for evidence-based decision making, a panel of informed experts and experienced clinicians utilized a Delphi process to establish consensus. The international literature was reviewed and discussed in the context of real world protocols.
Several clinical centres in Canada have developed successful programs for outpatient clozapine initiation. An experienced multidisciplinary team and the use of a standardized protocol is recommended in order to provide a reference framework for care. Education for patients, caregivers and HCPs is important and patient consent is required. A slow and cautious titration is necessary and side effects need to be well managed. Blood monitoring should be simple and convenient; point-of-care (POC) strategies may offer
better patient acceptance and tolerability.
Initiating clozapine in the out-patient setting is preferred under the right circumstances; knowledge and comfort about clozapine is critical to success. Out-patient clozapine initiation is cost effective, reduces pressure on hospital beds and decreases stress on patients. However, it does require preparation and infrastructure that takes into account clinical settings and patient complexity.