ANC monitoring for non-clozapine antipsychotics

[SpongeBob DoctorPants]

I have a patient on Seroquel, and on a blood draw the ANC was found to be 1.2, which is down from 1.8 a year ago. Are there any guidelines for monitoring this when a patient is not on clozapine? (For clozapine, in this case it would be recommended to repeat the CBC three times a week until the value reaches 1.5, but we're not dealing with clozapine here, so I'm wondering what the general consensus is on repeating labs when the risk for agranulocytosis is not as high.)

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[SpongeBob DoctorPants]

To answer my own question, and to help anyone else who may be wondering, I found this information on UpToDate:

For patients with uncomplicated, mild or moderate neutropenia, the ANC should be documented by serial complete blood counts (CBC). As an example, CBCs can be repeated weekly for the first two to four weeks, and again at three months:

If neutropenia resolves and the patient remains asymptomatic, there is no need for further follow-up. However, the patient should be re-evaluated urgently if fever or other infectious symptoms arise in the first year.

If mild neutropenia (>1000 cells/ microL) persists, a CBC should be repeated every three to four months for the first year, and if stable, further evaluated only if the patient becomes symptomatic with fever, mouth sores, or other signs of a hematological disorder. The patient should be evaluated for fever or other infectious symptoms, but no other routine follow-up is required.​

If anyone has anything else to add, your comments are appreciated.

 

[NickNaylor]

I haven't seen any nationally-produced guidelines that recommend CBC/ANC monitoring for antipsychotics under then clozapine. Most guidelines recommend a basic lab work-up - including an ANC - when you first start an antipsychotic, but I don't know of any guidelines that recommend regular ANC monitoring.

Take that for what it's worth. Clinical judgment in any one case would obviously supercede generalized guidelines.

 

[whopper]

Many psychotropic meds including all antipsychotics, Mirtazapine, Depakote and others can cause Neutropenia. It's just that with Clozapine the risk is to the degree where monitoring is mandatory where the others will cause a very subtle drop and the risk is small enough for the FDA not to require monitoring.

But if you have someone on any of the meds that can lower it, yes you could significantly worsen Neutropenia although the risk is low. If someone you gave, say Mirtazapine, had significant Neutropenia to the degree where there was a bad-outcome and you never did labs, you'd beat a malpractice case cause it's not within the standard of care, but that doesn't mean you don't have to care about it. Anyone on any psych meds it's a good idea to see them as a whole person you're treating and factor in their ANC levels.

Depakote, actually, IMHO should have ANC levels monitored and the CBC labs needed for it will usually include an ANC level. I've seen several patients get neutropenia from it even more so than Clozapine. While the risk is lower per patient vs Clozapine, Depakote is much more commonly prescribed-hence why I saw more Neutropenia with it.

The ANC drop is also of concern on anyone on mulitple meds where they can all cause this even if none of them are Clozapine because together it could cause a cumulative reaction where the ANC drop is significant. E.g. Mirtazapine + Olanzapine + Depakote.