Clozapine

INTRODUCTION

Indications

Schizophrenia unresponsive to or intolerant of standard therapy with other antipsychotics (treatment refractory). To reduce recurrent suicidal behavior in schizophrenic patients.

Action

Binds to dopamine receptors in the CNS. Also has anticholinergic and alpha-adrenergic blocking activity. Produces fewer extrapyramidal reactions and less tardive dyskinesia than standard antipsychotics but carries high risk of hematologic abnormalities. Therapeutic Effects: Diminished schizophrenic behavior. Diminished suicidal behavior.

Adverse Reactions/Side Effects

CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, dizziness, sedation. EENT: visual disturbances. CV: MYOCARDITIS, hypotension, tachycardia, ECG changes, hypertension. GI: constipation, abdominal discomfort, dry mouth, ↑ salivation, nausea, vomiting, weight gain. Derm: rash, sweating. Endo: hyperglycemia. Hemat: AGRANULOCYTOSIS, LEUKOPENIA. Neuro: extrapyramidal reactions. Misc: fever.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Watch for and report signs of neuroleptic malignant syndrome, including hyperthermia, diaphoresis, generalized muscle rigidity, altered mental status, tachycardia, changes in blood pressure (BP), and incontinence. Symptoms typically occur within 4–14 days after initiation of drug therapy, but can occur at any time during drug use.

• Be alert for new seizures or increased seizure activity, especially at the onset of drug treatment. Document the number, duration, and severity of seizures, and report these findings immediately to the physician.

• Monitor and report signs of myocarditis, including unexplained fatigue, dyspnea, tachypnea, fever, chest pain, palpitations, ECG changes (ST-T wave abnormalities), tachycardia, and other arrhythmias. Clozapine is usually discontinued if these symptoms occur.

• Be alert for signs of agranulocytosis and leukopenia, including fever, sore throat, mucosal lesions, and signs of infection. Report these signs to the physician immediately.

• Assess motor function, and be alert for extrapyramidal symptoms. Report these symptoms immediately, especially tardive dyskinesia, as this problem may be irreversible. Common extrapyramidal symptoms include:

  • Tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities, lip smacking or puckering, puffing of cheeks, uncontrolled chewing, rapid or worm-like movements of tongue).

  • Pseudoparkinsonism (shuffling gait, rigidity, tremor, pill-rolling motion, loss of balance control, difficulty speaking or swallowing, mask-like face).

  • Akathisia (restlessness or desire to keep moving).

  • Other dystonias and dyskinesias (dystonic muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs).

• Assess BP and compare to normal values (See Appendix F). Report changes in BP, either a problematic decrease in BP (hypotension) or a sustained increase in BP (hypertension).

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report a rapid heart rate (tachycardia) or signs of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess dizziness and sedation that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to ...