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poppy

before strting clozapine

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Does anyone use any tools/scales to measure the symptom before starting clozapine and subsequently to measure the response to medication.

          The reason i am asking this is, i have started an young man on clozapine and he is currently on 500mg ; but nil response.The main reason to start clozapine was predominently negative symptoms.What would be the further options? Shall i increase  clozapine further or add an antidepressant? any information on symptom measuring scales?

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The Nursing staff on the ward or CPN's in the community do a 'KGV'.Presumably it contains some stuff on negative symptoms. But to the best of my knowledge, there is no stead fast rule(of doing a scale before and after clozapine).

I suggest you do a serum clozapine level for this patient and if the levels are 0.35 and above then go for an antidepressant possibly citalopram or fluoxetine.If the levels are below 0.35 then increase the clozapine by 25 mgs.remember it may take a couple of weeks to get the levels back.so risk assessment in the interim is absolutely vital.(may be admit or get a CPN to monitor him on a regular basis)

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CGI (Clinical Global Impression) scores are sometimes used by Pharmacists. I find PANSS (Positive and Negative Symptoms Scale) quite useful. Ofcourse, if you are a puritan, you need formal training to administer PANSS. But use of PANSS is not very difficult and you don't need much training. Your experience in Psychiatry is good enough.

Hope you will find this article on management of clozapine non-responders in APT useful. (Management of Clozapine resistant schizophrenia, vol 11 pages 101-106, year 2005)

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I guess it's late now to measure pre-Clozapine scores, as he's already on Clozapine. But you can still use PANSS. And what about assessing depression? You could use the Calgary.

I suggest you do a serum clozapine level for this patient and if the levels are 0.35 and above then go for an antidepressant possibly citalopram or fluoxetine

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Yes I would agree with Oreta - it would be worth considering what it is ur treating; -ve symptoms of schizophrenia or affective symptoms. If the former then check u have the right dose or consider augmentation with amisulpiride or whatever the new fad is.

PANNS is good but a bit of an arse to administer properly especailly outside of research settings (ie busy wards, with plenty else to do) -which is what is it generally designed for (ie to standardize the findings for a patient in the context of a cohort).

Of course consult ur supervisor/RMO. Another alternative is to call up the Maudsley Medicines information line for a bit of meds advice. Very well informed pharmacists (with lots of evidence to back up their advice) and open to calls from anywhere (9-5 only!)

tel: 020 7919 2317

Finally and not that i am at all impressed with what drug reps go on about but isnt on of the new anti-psychotics supposed to be very good at targetting -ve symptoms - ? ariprazole. In all likelyhood a pile of p@nts but ?worth a shot?? ;)

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there is no evidence that aripiprazole is good for negative symptoms. and the reps (usually) don't promote it for them either - they tell you about the DA hypothesis (low DA=-ve sx, high DA-+ve sx) then tell you that aripip is a partial agonist and balances DA levels so where there is high DA it lowers it and where there is low DA it increases it.

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I guess my consultant was using Aripiprazole since even before july 05 and I have seen good response in a number of patients.This medication is really worth a try!

cheers

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I guess my consultant was using Aripiprazole since even before july 05 and I have seen good response in a number of patients.This medication is really worth a try!

cheers

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I have heard of case reports of Clozapine Augmentation with Lamotrigine being good for patients with residual negative features. Check with your Trust Pharmacy & look in the Psychotropic Drug Directory by Stephen Bazire.

To be honest, I dont see the relevance of outcome scales in daily practice.Heck, just my view.

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Clozapine augmentation - fascinating stuff.

1. Look at dose of clozapine. Check level - take in account smoking and other drugs. Compliance, illicit drugs, organic illness etc.

2. increase dose to BNF max if tolerable.

3. supplement with amisulpiride - up to 400 mg. Stay within BNF limits.

4. Some evidence with lamotrogine, risperidone, valproate, Omega 3.

5. Look at other drugs.

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some evidence with all sorts of other things. sulpiride has an rct i think. haloperidol also some evidence. cbt? even aripiprazole.

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