Comparison of clozapine monitoring and adverse event management in a psychiatrist-only and a clinical pharmacist-psychiatrist collaborative clinic

Abstract

Introduction: In an effort to establish clinical support for providers prescribing clozapine and to help reverse the national decline in clozapine utilization, a clinical pharmacist began seeing half the clozapine clinic patients, preceding the psychiatrist, at this facility in July 2017. The other half of the clozapine clinic patients continued being seen by the psychiatrist only. The purpose was to determine the impact of the pharmacist on clozapine management and identify barriers to clozapine use to potentially increase its utilization.

Methods: Baseline data (clozapine dose, number of antipsychotics and other psychotropics, A1c, lipids, pulse, body mass index, weight, blood pressure, and number of medications for adverse effects) were collected via chart review from the first clinic visit and each follow-up visit. A provider survey was used to identify barriers and solutions to prescribing clozapine.

Results: There were no statistically significant differences from baseline in patient outcomes between the collaborative and psychiatrist-only group. In the prepharmacist to postpharmacist analysis, there was a decrease in number of antipsychotics (-0.27 ± 0.65), number of other psychotropics (-0.18 ± 0.41), A1c (-0.04% ± 0.25%), clozapine dose (-7.96 mg ± 19.58 mg), and total cholesterol (-15.73 mg/dL ± 42.31 mg/dL). There were more pharmacologic (71 vs 19) and nonpharmacologic (154 vs 3) interventions documented in the collaborative group compared to the psychiatrist-only group. Eleven providers (69%) completed the survey. Providers' perception of patient refusal of monitoring was the barrier that received the most responses (54%). A pharmacist seeing every clozapine clinic patient was the solution that received the most responses (90%).

Discussion: Trends were seen for decreasing the number of antipsychotics, other psychotropics, A1c, and total cholesterol as well as an increased number of nonpharmacologic and pharmacologic interventions documented in the collaborative group. Providers identified that pharmacists seeing every clozapine clinic patient would be a solution to clozapine underutilization, which demonstrates the perceived value of pharmacist involvement.

Keywords: clozapine clinic; clozapine underutilization; pharmacist intervention; pharmacist monitoring.