Clozapine 200

Armin Moradi

2021-03-04

Previously on Clozapine…
Effects and side effects
Constipation
Constipation - agents
Constipation - ileus
Constipation - treatment
Sialorrhea
Sialorrhea - scales
Sialorrhea - treatment
Summary

Previously on Clozapine…

amoradi.org/public/clozapine.html

Effects and side effects

maaaaaaaaaaaany

Constipation

anticholinergic effects
constipation and ileus

Clozapine has anticholinergic side effects before the blood brain barrier, and so it causes constipation and ileus.

Because the effect is anticholinergic in nature, you should also avoid other anticholinergic drugs

So the way you manage constipation in clozapine patients is almost the same as any other constipation patient, the keyword being almost.

evaluate constipation in all patients started on clozapine
remove other anticholinergic or constipation-inducing agents before starting clozapine
start meds with first clozapine prescription for every patient even if constipation is not a current issue, because it will be
many patients need one med from each class of meds, no more than one per class
no bulk-forming agenst (transit time is slow already, don't make it worse)
48 hours tops per med/dose change
watch out for ileus

Constipation - agents

anionic detergent: docusate
osmotic agent: PEG, lactulose
stimulant: Bisacodyl, sennosides

Constipation - ileus

more people die from ileus than agranulocytosis

Constipation - treatment

Porirua protocol for clozapine constipation
docusate + senna -> PEG -> poop maestro

Sialorrhea

Cholinergize You Mind (TM)

Sialorrhea - scales

C D E F G A B
D S F S (<=2) and N H S (<2)
lip > chin > clothing > body
NHS = # of awakening + 1

Sialorrhea - treatment

DSFS and NHS
atropine -> botox -> clonidine

The first line of treatment should be topical. topical atropine 1% eye drops are effective in taking care of most cases. But I've heard they taste pretty bad, so patients might not like it.

1-3 drops qHS, up to 3 drops tid. or ipratropium 1-3 sprays qHS up to 3 sprays tid

If that doesn't work, then botox injection into salivary glands can be effective. This can be done by anyone who's comfortable, so ENT, plastics, your local drool bender.

Then if that still doesn't work, think about non-anticholinergic options like alpha-adrenergic agents like clonidine (we don't have amisulpride in canada)

Lastly, if nothing works, you're out of options. think about systemic anticholinergic, but watch out for GI hypomotility and ileus (2x increased risk of ileus). glycopyrrolate has been shown to be effective. Loooots of caution needed though.

Summary

many side effects
to be continued!