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Original papers: Anna Sparshatt, Eromona Whiskey, and David Taylor Valproate as prophylaxis for clozapine-induced seizures: survey of practice Psychiatr Bull 2008; 32: 262-265 [Abstract] [Full text] [PDF]

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Community Patients prescribed Clozapine: high number rated 'at risk'

Joan Rutherford, Sara Beleil and Nanaji Pala   (16 October 2008)

Community Patients prescribed Clozapine: high number rated 'at risk' 16 October 2008
Joan Rutherford South West London and St George's Mental Health NHS Trust, Sara Beleil and Nanaji Pala Send letter to journal: Re: Community Patients prescribed Clozapine: high number rated 'at risk' Joan.Rutherford{at}swlstg-tr.nhs.uk Joan Rutherford, et al.	We read with interest the survey by Sparshatt et al on the use of Valproate as prophylaxis for Clozapine induced seizures. It spurred us on to do a similar survey within Kingston Community Mental Health Team, and we were surprised at how many of our patients were rated as high risk. Within our team there are a total of 244 patients of which 94 (39%) are diagnosed with schizophrenia or schizo- affective disorder. Of the 94, 41 (44%) are considered treatment resistant, and 15 are prescribed Clozapine. At the time of our survey none of the 15 were inpatients. Using the same criieria as Sparshatt et al ie Clozapine level 0.6 mg/l or more, or dose at/more than 600 mg /day or co-prescribed additional epileptogenic medication and/or with an existing seizure disorder, we found five patients, ie 40% of our sample, were high risk and this was due to having a Clozapine level over 0.6 in all five cases. Two of these patients had had seizures since commencing Clozapine and both were prescribed Valproate. Another two were also prescribed epileptogenic medication. Our survey raised three issues for us: Firstly,the Maudsley Guidelines suggest prescribing Valproate if Clozapine serum level is at or greater than 0.5mg/l, so we wondered why the level of 0.6 mg/l was selected the high risk level. Secondly, we did not see any reference to the smoking status of the patients in the survey, although the Maudsley Guidelines do comment about lower Clozapine serum levels in smokers. One of our 15 patients reported markedly increased sedation after he stopped smoking. Although his Clozapine serum levels increased by 100%, at no time was this over 0.6 mg/l, but we wondered whether smoking cessation in patients on Clozapine could or should trigger them into the high risk group. Thirdly, we wondered whether the Maudsley Guidelines could offer further advice to clinical teams on Clozapine serum levels? We would appreciate advice when our patients take Clozapine at split doses, morning and evening, as we are not clear the impact this has on the serum Clozapine level; also as to whether the Guidelines could advise on good practice with regard to the intervals between Clozapine serum level sampling. Yours sincerely Drs Joan Rutherford, Sara Beleil and Nanaji Pala Refs: SPARSHATT, A., WHISKEY, E. and TAYLOR, D. (2008) Valproate as prophylaxis for clozapine-induced seizures: survey of practice. Psychiatric Bulletin, 32, 262-265. TAYLOR, D., PATON, C. and KERWIN, R (2007) The Maudsley Prescbing Guidelines 9th Edition. Informa Healthcare.