By Marvin Ross
Quite frequently, there are demands from families that the prescribing of clozapine should be more readily made and that the required blood monitoring as a condition of taking it should end. These are based on the belief that clozapine is more effective than anything else and that the side effect is rare. That side effect destroys all white blood cells leaving the patient with a vastly reduced immune system. It happens in about 1% of patients. It is rare but devastating when it occurs.
It may well be the most effective anti-psychotic (for some people anyway) but the most effective one is the drug that works best for an individual with a minimum of negative side effects. We are all different and what works for one person may not work for another. This makes treating schizophrenia so difficult and frustrating. A treatment trial can take months before results are seen and then even longer to see if the positive impacts last and the side effects are minimal and manageable.
This phenomenon isn’t restricted to schizophrenia but to all medical conditions although the waiting time to see effect is likely longer with schizophrenia. My son has been through a number of different drugs including clozapine but changes needed to be made at different times. In his case, clozapine was like a miracle, had no negatives and lasted for a number of years. Then it became less effective and we were faced with relapses. At that point he was switched to Abilify and he improved again.
In her memoir, When Quietness Came, Erin Hawkes found that, nothing worked and she ended up with about a dozen involuntary hospitalizations until Abilify was approved. It worked for her and now she is married and has a child. All those involuntary hospitalizations, as Erin wrote, saved her life.
The serious side effects of anti-psychotics are weight gain, metabolic dysregulation, and increased risk of diabetes, further contributing to elevated cardiovascular risk. Clozapine and olanzapine have the greatest metabolic risk of this class of drugs even with a short treatment time. These side effects can result in mortality of 2-3 times higher and a life span shortened by a good 15 years.
But patients are all different. My son gained a tremendous amount of weight on olanzapine but there was no weight gain with clozapine. Add on treatments to deal with weight gain are of limited value. But what twigged me to write this blog is a new study just published that Dr David Gratzer of CAMH talked about in one of his recent mailings on Readings of the Week.
JAMA Psychiatry published a new randomized placebo controlled trial in people with schizophrenia spectrum disorder on the use of the new injectible weight loss drug that you see constantly advertised ad nauseam on TV. The findings:
“In this trial, 26 weeks of treatment with once-weekly semaglutide (target, 1 mg) significantly improved glycemic control and weight-associated outcomes in individuals with schizophrenia spectrum disorders and early-stage glycemic dysregulation who recently initiated treatment with clozapine or olanzapine.”
“Wow” said Dr Grazer. There was a 43% reduction in the blood sugar marker (HbA1c) for those on the semaglutide compared to only a 3% reduction for those on placebo. Of course, it was a small sample and the drug is expensive so good luck trying to get insurance companies or the government to pay for it. But, frankly, it seems worthwhile to explore and do more studies and to then lobby to have this added to the approved treatment regimen for those with drug induced weight gain.
Clozapine should be tried more than it is now but many are wary of prescribing it unless you live in an area where doctors have more expertise. What I found more annoying about the blood testing was the rigidity of staff. My son was told that he had to go monthly to a specific lab to get blood drawn. It was difficult for him to get to it so I told him to go elsewhere. The agency staff told him he couldn’t because the lab they wanted him to use was the only lab that could do clozapine testing. That was a total lie or, if it wasn’t, they were totally stupid.
Blood labs are usually only collection stations and the actual analysis is done in a centralized laboratory. The blood test itself is one of the most common called a CBC or Complete Blood Count and measures the amount of red and white blood cells along with a few other things. The staff were just too lazy to fill out a new requisition. I mentioned this to the psychiatrist who I got along with well and he said of course go somewhere else, pulled out a requisition form, signed it and handed it over.
The things we families and our ill relatives had to deal with.
Dr Dawson’s first experience prescribing clozapine years, however, was not particularly positive. He said:
Clozapine had just been made available to Ontario hospitals. A teen age girl is admitted to one of the wards. She has been suffering from schizophrenia for a few years but treated at home by an Italian speaking psychiatrist.
The drugs stop working. She is admitted. The doc on the ward wants to try clozapine. The parents are balking, They are Italian immigrants. I am called in to help.
I have a long talk with mom and dad, even use my bits of Italian, end up getting invited to try some of the father’s home made wine, and I promise them no harm will come to their daughter.
The daughter goes on clozapine. About 10 days later she has a seizure.
I meet with the parents. I expect them to be really upset. I tell them we now have two options. Go off the clozapine and try something else, or add anti-seizure meds. They say she’s been so much better lately, we have our daughter back, that they want to continue clozapine with the anti-seizure medication. We do this. She keeps improving. About two weeks later her white blood count plummets.
On an other note, Christmas is almost upon us so David and I are going to take some time to rewind and we will be back in 2026.
We hope you all have a safe, healthy, happy holiday season with no added stress or crises.
