ABSTRACT
Introduction: Despite treatment guidelines for schizophrenia less than 25% of individuals with schizophrenia who meet Treatment Resistant Schizophrenia [TRS] criteria are actually receiving clozapine. On average, it takes 9 years before a patient is initiated on clozapine. Over this time, period patients will typically receive at least 7 different antipsychotics and 2/3 will have been prescribed 3 or more antipsychotics together. Treatment delay is correlated with impaired functionality, poorer outcome and greater disease burden and costs. Aims: Despite the effectiveness of clozapine, there is a reluctance to use it because of patient concerns, e.g., frequent blood tests;physician concerns, e.g., risk of agranulocytosis and lack of experience;system issues, e.g., registration and monitoring requirements;and medication complexity, e.g., dosing and titration [1]. This has been further impacted by the COVID-19 pandemic, with patients either not being initiated or switched because of concerns about difficulties in blood monitoring [2]. Clozapine utilization has been shown to increase with implementation of specific educational programs, audits, clozapine clinics and point of care testing [3] involvement of allied health care professionals such as pharmacists. We collected data on a unique pilot initiative using Point of Care Monitoring (POCM) to address the barrier of blood monitoring in a community setting. Methods: A POCM device (PRONTOTM) was approved in Canada in November 2019, which allows for real-time evaluation of white blood cell and neutrophil counts from a capillary sample. Patients registered to the Clozaril® Support and Assistance Network (CSAN) were switched from regular laboratory service to POCM conducted by on-site nursing staff in a group home setting. In a Quality Improvement (QI) project patients and staff were asked to evaluate their experiences. Results: A total of 152 POCM tests were conducted in 26 patients on clozapine who previously attended at a local laboratory. Overall adherence to CSAN monitoring was improved, and there was a high degree of patient acceptance and preference for POCM. The nursing staff reported high satisfaction and convenience with time saving. All patients switched to POCM have continued with it. Particular advantages included monitoring being carried out by consistent (and trusted) staff and the small sample size required. Conclusion: This is the first evaluation of POCM for clozapine in the community and potentially removes barriers to clozapine use given the simplicity, flexibility, rapidity, and convenience, as well as ease of use and decreased invasiveness. Patients were more cooperative and it is cost-effective as patients do not need to be transported to the laboratory. Further, POCM may contribute to the safer monitoring of clozapine patients in the current COVID environment. Improved patient care and increased adherence to monitoring results in potentially better outcomes. The next step is to demonstrate that patients can be safely initiated on clozapine in the community with POCM, thereby obviating the necessity of a hospital admission with associated cost and risk. Ultimately, the goal is the more appropriate use of clozapine with early and simple access consistent with treatment guidelines for schizophrenia. Conflict of interest Disclosure statement: I have received educational, research and tracvel grants and honoraria from Otsuka, Janssen, Mylan, HLS, Lundbeck, Novartis, Pfizer, Hoffmann La Roche, AbbeVie. Alkermes, and Kye