Patient not obtaining weekly ANC for clozapine but its been the only thing that stabilized her

[deleted1100659]

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Basically patient does not do well off clozapine and has failed every medication you can think of. She had been on it before and was doing well, but she was off it for a prolonged period of time, then came to me. After I discussed it with the family, gave them a titration schedule, etc I prescribed it and shes doing very well now.

Unfortunately shes on weekly monitoring and has missed a few ANCs..I belive she has clozapine left over from last provider and thats how theyre making it.

I dont see any great solution to this besides cross tapering off and possibly switching to high dose zyprexa because even if I dont take her off of it, the pharmacy will stop filling the rx without the ANC.

Obviously ECT isnt an option since the family is not doing a good job with even weekly blood draws (which is annoying since we have a lab on site and virtually no wait, can just walk right in).

Im going to recommend she goes to a PCH where they can ensure she gets taken to appts/labs but that process can take a while anyways and is dependent on the family.

Any other ideas?

 

[pazzer2]

Clozapine is used very widely in China (up to half of patients), even first line. Not all patients have routine monitoring of their ANCs there. And they have pretty good outcomes. I think the risk of agranulocytosis is highest in the first 3 months after starting. After that the risks are lower.

I know this doesn't keep you from worrying about the patient, but I thought I'd share.

Clozapine in China - PubMed

Clozapine remains one of the most commonly used antipsychotic medications in China. As China has the largest population internationally on clozapine treatment, its experience and research findings are of keen interest to Western psychiatrists. However, most of the related papers have hitherto...

pubmed.ncbi.nlm.nih.gov

 

[deleted1100659]

Clozapine is used very widely in China (up to half of patients), even first line. Not all patients have routine monitoring of their ANCs there. And they have pretty good outcomes. I think the risk of agranulocytosis is highest in the first 3 months after starting. After that the risks are lower.

I know this doesn't keep you from worrying about the patient, but I thought I'd share.

Clozapine in China - PubMed

Clozapine remains one of the most commonly used antipsychotic medications in China. As China has the largest population internationally on clozapine treatment, its experience and research findings are of keen interest to Western psychiatrists. However, most of the related papers have hitherto...

pubmed.ncbi.nlm.nih.gov

well I think one of my main concern is that regardless of me, the pharmacy wont fill it without an ANC so eventually shell go off it anyways when they dont refill it and then we would have to just retitrate anyways and be back to square one

 

[Bartelby]

Can you hammer the importance of this home with the family and recruit some of them to help with getting the lab draws?

 

[clausewitz2]

Yeah unfortunately your hands are kind of tied here. The REMS systems does not allow you a tremendous degree of wiggle room here if you aren't able to monitor at the frequency they insist on. I agree that the empirical evidence suggests this is probably wildly too conservative (especially given the impacts our other medications have on people all the time). Do you have any idea why the family is struggling with this, given you have a rarely-busy lab right on site? Identifying the obstacles might actually mean a potential solution suggests itself.

 

[deleted1100659]

To answer the above- hammered the family so many times. Annoying part is, she has a big family who are reasonably intelligent. Mother was probably the most consistent at taking her in past but mothers health is declining. However, she has other family members who had involvement in bringing her but they have not been consistent.

We have an onsite lab that is not busy at all and easily accessible and they know this information well.

I think at this point despite me explaining it multiple times the family assumes they can just get away with not taking her for blood draws because it may be somewhat inconvient, I dont think itll fully dawn on them until she runs out.

The mother being sick does make it harder, but the rest of the family hasnt seemed to really step up.

 

[Celexa]

To answer the above- hammered the family so many times. Annoying part is, she has a big family who are reasonably intelligent. Mother was probably the most consistent at taking her in past but mothers health is declining. However, she has other family members who had involvement in bringing her but they have not been consistent.

We have an onsite lab that is not busy at all and easily accessible and they know this information well.

I think at this point despite me explaining it multiple times the family assumes they can just get away with not taking her for blood draws because it may be somewhat inconvient, I dont think itll fully dawn on them until she runs out.

The mother being sick does make it harder, but the rest of the family hasnt seemed to really step up.

I agree your hands are tied and they won't change their behavior until they hit a consequence. I do find pharmacies adherence to clozapine dispensing ruled to be wildly variably (more so with covid, when the rules were relaxed) so you might debate continuing to send prescriptions vs cutting that off even earlier than the pharmacy may. But either way the pt at least temporarily going off clozapine seems inevitable. It's unfortunate but it's not on you.

 

[PikminOC]

Clozapine is used very widely in China (up to half of patients), even first line. Not all patients have routine monitoring of their ANCs there. And they have pretty good outcomes. I think the risk of agranulocytosis is highest in the first 3 months after starting. After that the risks are lower.

I know this doesn't keep you from worrying about the patient, but I thought I'd share.

Clozapine in China - PubMed

Clozapine remains one of the most commonly used antipsychotic medications in China. As China has the largest population internationally on clozapine treatment, its experience and research findings are of keen interest to Western psychiatrists. However, most of the related papers have hitherto...

pubmed.ncbi.nlm.nih.gov

This is the us of lawyers

 

[clozareal]

There's one POC device in the US that's approved for CBC/ANC. Something to consider as it might make it easier for the patient (I have no financial interest in them).

Athelas Home - At Home Blood Diagnostics in Minutes for Neutrophil & White Blood Cell Counts

FDA-cleared at-home blood diagnostics device simplifies blood monitoring process for patients prescribed clozapine. Getting a simple, onsite finger-prick is easy, eliminates the need for a venous draw, and the device returns neutrophil count within minutes.

www.athelas.com

 

[comp1]

Concur with the upside here being that this is not a decision you get to make. The pharmacy will be making it for you via REMS. You can only try to motivate the family, which it seems you have. This is why I see very, very few SMI patients on clozapine even after failing every other antipsychotic. Our medical and mental health system, unlike Europe's, is not in any way set up for it to be successful. I've never heard of the POC device. That could be a game changer, but your patient at least has indifferent family which is more than I can say for most. Most have nobody and nothing.

 

[hallowmann]

Yeah unfortunately your hands are kind of tied here. The REMS systems does not allow you a tremendous degree of wiggle room here if you aren't able to monitor at the frequency they insist on. I agree that the empirical evidence suggests this is probably wildly too conservative (especially given the impacts our other medications have on people all the time). Do you have any idea why the family is struggling with this, given you have a rarely-busy lab right on site? Identifying the obstacles might actually mean a potential solution suggests itself.

This is exactly what needs to happen, it also needs to be emphasized that this is TEMPORARY while you are making sure she does not have an adverse reaction and that it stretches out to monthly.

To answer the above- hammered the family so many times. Annoying part is, she has a big family who are reasonably intelligent. Mother was probably the most consistent at taking her in past but mothers health is declining. However, she has other family members who had involvement in bringing her but they have not been consistent.

We have an onsite lab that is not busy at all and easily accessible and they know this information well.

I think at this point despite me explaining it multiple times the family assumes they can just get away with not taking her for blood draws because it may be somewhat inconvient, I dont think itll fully dawn on them until she runs out.

The mother being sick does make it harder, but the rest of the family hasnt seemed to really step up.

Yeah, it sucks, but its not on you. She can't fill it without ANCs, and you can't make her go to the lab. I'm assuming there are no easier labs for her to get to that might fit a family member's home/work schedule better. Does she have an insurance that facilitates ride scheduling?

If they could just make sure she is ready, you could have a regular ride for her scheduled through insurance to get her to your facility and back home every week.

This really is one of those situations where a brief stint with an ACT team or just a weekly home nursing visit would really be helpful. I don't know details about the patient, but I would talk to support staff or case management if they're available to you or the patient to problem solve what can be done. Often times this stuff takes a lot of time, but some of the insurance case managers are really proactive and a conversation with them can make a difference. All this stuff is wildly variable by region and insurance...

There's one POC device in the US that's approved for CBC/ANC. Something to consider as it might make it easier for the patient (I have no financial interest in them).

Athelas Home - At Home Blood Diagnostics in Minutes for Neutrophil & White Blood Cell Counts

FDA-cleared at-home blood diagnostics device simplifies blood monitoring process for patients prescribed clozapine. Getting a simple, onsite finger-prick is easy, eliminates the need for a venous draw, and the device returns neutrophil count within minutes.

www.athelas.com

Athelas actually does a ton of different labs. I have not used it personally and I don't know anyone that has, so I have no idea how reliable it all is or what the total costs end up being.

 

[Sikrouf]

I work in Europe
And luckily for me it took me 2 minutes yesterday to call the pharmacist, inform of the situation, and obtain a twice per month bloods surveillance for the first 6 months

 

[deleted1100659]

.

This really is one of those situations where a brief stint with an ACT team or just a weekly home nursing visit would really be helpful. I don't know details about the patient, but I would talk to support staff or case management if they're available to you or the patient to problem solve what can be done. Often times this stuff takes a lot of time, but some of the insurance case managers are really proactive and a conversation with them can make a difference. All this stuff is wildly variable by region and insurance...

Funny enough, reffered her to ACT team, but declined because she wasnt hospitalized enough recently for acute exacerbations. Countered with "I understand the logic of only taking sick people, but if were proactive instead of retroactive maybe we wont need to wait that long". tis the system...

 

[Celexa]

Funny enough, reffered her to ACT team, but declined because she wasnt hospitalized enough recently for acute exacerbations. Countered with "I understand the logic of only taking sick people, but if were proactive instead of retroactive maybe we wont need to wait that long". tis the system...

Ugh I know this feeling all too well. Have literally had this exact conversation. The system is not set up for prevention until so much harm has already been done.

 

[hallowmann]

Funny enough, reffered her to ACT team, but declined because she wasnt hospitalized enough recently for acute exacerbations. Countered with "I understand the logic of only taking sick people, but if were proactive instead of retroactive maybe we wont need to wait that long". tis the system...

Yeah, unfortunately the ACT grants and funding as well as insurance companies that cover the patients usually specify who can be eligible, and in most cases they need repeated hospitalizations. It sucks, but is frustrating for everyone involved. Maybe when she decompensates and is hospitalized she'll qualify. The healthcare system is messed up...

 

[DJKitty]

I've had an inpatient that refused the blood draws, but had previously done well on clozaril. We started him on loxitane because the similar binding profiles and similar chemical structures. My attending had found a couple of case series on using loxitane in patients who could no longer tolerate clozaril. So far so good; however, I know n = 1.

 

[Orgone]

There's one POC device in the US that's approved for CBC/ANC. Something to consider as it might make it easier for the patient (I have no financial interest in them).

Athelas Home - At Home Blood Diagnostics in Minutes for Neutrophil & White Blood Cell Counts

FDA-cleared at-home blood diagnostics device simplifies blood monitoring process for patients prescribed clozapine. Getting a simple, onsite finger-prick is easy, eliminates the need for a venous draw, and the device returns neutrophil count within minutes.

www.athelas.com

I know a long-term inpatient facility that uses these. Patients are much, much happier. I have no doubt the costs are prohibitive at this point, but it's nice to daydream of a time when we can just prescribe these with clozaril the way our medicine friends prescribe lancets with insulin.

 

[ObsequiousAplomb]

Isn't what Athelas is offering very similar to Theranos? Has the technology really improved that much?

 

[Candidate2017]

To answer the above- hammered the family so many times. Annoying part is, she has a big family who are reasonably intelligent. Mother was probably the most consistent at taking her in past but mothers health is declining.

We have an onsite lab that is not busy at all and easily accessible and they know this information well.

You've done your job, rest easy.

You gave them your recommendations (and alternative choices that account for their limitations), identified obstacles, encouraged, nagged. The rest is up to them, their families, social work and society.

In outpatient psychiatry, we're merely doctors who highlight the path(s). Even surgeons who wield the unilateral power to heal with steel have zero control over whether their patients choose to do something as simple as take post-op antibiotics or make a follow up appointment.

It's tough to see patients get in their own way, but I remind myself:
You can lead a horse to water, but...
If you're working harder than the patient...
God grant me the wisdom to recognize the things I can or cannot...

 

[Animal Mother]

This is exactly what needs to happen, it also needs to be emphasized that this is TEMPORARY while you are making sure she does not have an adverse reaction and that it stretches out to monthly.



Yeah, it sucks, but its not on you. She can't fill it without ANCs, and you can't make her go to the lab. I'm assuming there are no easier labs for her to get to that might fit a family member's home/work schedule better. Does she have an insurance that facilitates ride scheduling?

If they could just make sure she is ready, you could have a regular ride for her scheduled through insurance to get her to your facility and back home every week.

This really is one of those situations where a brief stint with an ACT team or just a weekly home nursing visit would really be helpful. I don't know details about the patient, but I would talk to support staff or case management if they're available to you or the patient to problem solve what can be done. Often times this stuff takes a lot of time, but some of the insurance case managers are really proactive and a conversation with them can make a difference. All this stuff is wildly variable by region and insurance...


Athelas actually does a ton of different labs. I have not used it personally and I don't know anyone that has, so I have no idea how reliable it all is or what the total costs end up being.

I have an Athelas in my office and use it for all of my clozapine patients. There is no cost. It's a free machine/service. They just ask you use their pharmacy to dispense clozapine.

 

[clozareal]

Isn't what Athelas is offering very similar to Theranos? Has the technology really improved that much?

No. They're offering CBC with diff only. There are POC devices that are for single lab tests such as insulin and ones in research such as for troponin. Theranos was trying to use a single drop of blood for a wide range of blood tests, not just one blood test, and it was not FDA approved. They published a paper that showed their tests were way outside the range in terms of accuracy.

Athelas got FDA approved after publishing their ANC and WBC values were equivalent to an automated hematology analyzer.

 

[ObsequiousAplomb]

No. They're offering CBC with diff only. There are POC devices that are for single lab tests such as insulin and ones in research such as for troponin. Theranos was trying to use a single drop of blood for a wide range of blood tests, not just one blood test, and it was not FDA approved. They published a paper that showed their tests were way outside the range in terms of accuracy.

Athelas got FDA approved after publishing their ANC and WBC values were equivalent to an automated hematology analyzer.

Thank you. I'm glad my fear wasn't accurate. Sounds like a pretty reasonable device, not the worst way to set up some in office monitoring.

 

[mistafab]

I think a discussion with the patient and all involved parties would be the way to go. Bring up treatment options, including less optimal treatments, and likely risks/benefits. A quick family meeting like this may not get the patient to stay on clozapine, but at least everyone feels good about the decision being made. We already know that social support is as important as medications, so involving the family and getting everyone on board for a treatment plan, even a less optimal one, may have benefit for the patient long term. Especially when the mom inevitably passes away somewhere down the road.

 

[whopper]

Someone I know is one of the country's top ranked psychiatrists and pushed for a "reawakening" of Clozapine. I had a talk with him about it just a few days before I left my professor's position.

It was all well and good but I didn't have the heart to push to him why I felt Clozapine really isn't prescribed much. It's cause of what's all written above. If you have a patient on Clozapine and they don't do labs it's a freaking headache.

Add to the above that if the patient does a lab, unless that lab is directly linked to your EHR, you will have problems getting the results. From my clinical experience hospitals and private labs only send labs to the office, even after they've verbally promised to do so within the same day, less than 25% of the time.

Usually in a university hospital the lab is nicely put into the cloud data within the day and you simply see it in the EHR. It doesn't work that way in private practice. Your patient often times goes to a hospital or lab outside your EHR system.

The psychiatrist I mentioned above never worked outside of academia. HE's a great guy and deserves the recognition as a top person in the field but he never dealt with the real-world reality of a lab not being faxed to your office despite that you, the patient, and your administrative assistant have contacted the lab over a dozen times in the last 24 hours each time with the lab promising they'll get you the results.

In cases like the above I've told the patient they have to go to the labs that from my personal experience didn't pull the above bull$hit, or get another psychiatrist attached to a hospital or university system where the labs will be put into the EHR without obstacle.