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12: Clozapine

Risk Management and Treatment » Pharmacologic Treatments
12: Clozapine

We suggest offering clozapine to decrease the risk of death by suicide in patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempt(s).

Strength:

Weak for

Category:

ReviewedAmended

Grades and Definitions

Strong for
or "We recommend offering this option …"
Weak for
or "We suggest offering this option …"
No recommendation
or "There is insufficient evidence …"
Weak against
or "We suggest not offering this option …"
Strong against
or "We recommend against offering this option …"

Categories and Definitions

Evidence Reviewed* Recommendation Category* Definition*
Reviewed New-added New recommendation following review of the evidence
New-replaced Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence
Not changed Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed based on review of the evidence
Not reviewed Not changed Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG
*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

Recommendation Resources

Clozapine is an atypical antipsychotic medication that has been found to reduce suicidal behaviors in patients diagnosed with schizophrenia or schizoaffective disorder. The CPG lit review found that the quality and consistency of studies was variable, with only one RCT of moderate quality that compared clozapine to an alternative antipsychotic, olanzapine. There are significant challenges to clozapine use in elderly or homeless patients because of the medication's side effects and difficulties in required monitoring. In the specific population of patients for whom the drug is indicated, the evidence is considered sufficient with small benefit. Current confidence in the quality of the evidence is low for reduction in suicide attempts and suicide.

Training Resources

This section includes links to training resources about offering clozapine to decrease the risk of death to suicide in patients with schizophrenia or schizoaffective disorder.

VA National Clozapine Coordinating Center
An invaluable resource for VA clozapine prescribers. NCCC can offer consultation for difficult cases, as well as, assist with logistics concerns related to prescribing within the VA and difficulties with CPRS related to clozapine. Questions can go: vhaclozapine@va.gov.
National Clozapine Coordination Center (NCCC) SharePoint (VA Intranet access required)
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Manuals

This section includes links to implementation manuals or resources about offering clozapine to decrease the risk of death to suicide in patients with schizophrenia or schizoaffective disorder.

VHA Directive 1108.17: Clozapine Patient Management Handbook
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Webinars

This section includes links to webinars that are recommended about offering clozapine to decrease the risk of death to suicide in patients with schizophrenia or schizoaffective disorder.

CPG Webinar Perceived Barriers and Facilitators of Clozapine Use: A National Survey of Veterans Affairs Prescribers Presented by Drs. Breanna Moody & Courtney Eatmon
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Articles

This section includes links to recommended articles about offering clozapine to decrease the risk of death to suicide in patients with schizophrenia or schizoaffective disorder.

Alphs, L., Anand, R., Islam, M. Z., Meltzer, H. Y., Kane, J. M., Krishnan, R., Green, A. I., Potkin, S., Chouinard, G., Lindenmayer, J. P., & Kerwin, R. (2004). The international suicide prevention trial (interSePT): rationale and design of a trial comparing the relative ability of clozapine and olanzapine to reduce suicidal behavior in schizophrenia and schizoaffective patients. Schizophrenia bulletin, 30(3), 577-586. https://doi.org/10.1093/oxfordjournals.schbul.a007102
Meltzer, H. Y., Alphs, L., Green, A. I., Altamura, A. C., Anand, R., Bertoldi, A., Bourgeois, M., Chouinard, G., Islam, M. Z., Kane, J., Krishnan, R., Lindenmayer, J. P., Potkin, S., & International Suicide Prevention Trial Study Group (2003). Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Archives of general psychiatry, 60(1), 82-91. https://doi.org/10.1001/archpsyc.60.1.82
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Podcasts

This section includes links to recommended webinars about Lethal Means Safety.

Podcast icon Consultant 360: Multidisciplinary Medical Information Network podcast- Unpacking Schizophrenia: Preventing Suicides Presented by Dr. Robert S. Laitman