Outpatient Initiation of Clozapine

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Presenting Author(s): Dr. Pierre Chue, MBBCh, FRCPsych, LMCC, FRCPC, DABPN, MSc, CCST.

Co-Author(s): Kathy Aitchison, David Bloom, Zahid Latif, Xin-Min Li, Gaurav Mehta, Toba Oluboka, Ron Pohar, Ajmal Razmy, Patrick White

Date and time: 23 Mar 2019 from 14:30 to 15:00

Location: Hawthorn A  Floor Map


  1. Review the under-utilization of clozapine;
  2. Understand the barriers to clozapine initiation; and
  3. Discuss protocols for clozapine outpatient initiation.

Literature References

  1. Chue P, Oluboka T, Pohar R. Clozapine in the current management of schizophrenia. Pear Health eLearning. Canadian Council on
    Continuing Education in Pharmacy Accredited Self Assessment Program 2017.
  2. Tungaraza TE, Ahmed W, Chira C, et al. Prescribing pattern of clozapine and other antipsychotics for patients with first-episode
    psychosis: a cross-sectional survey of early intervention teams. Ther Adv Psychopharmacol. 2017;7(3):103-111.
  3. Gee SH, Shergill SS, Taylor DM. Patient attitudes to clozapine initiation.
  4. Int Clin Psychopharmacol. 2017;32(6):337-342.


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.

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