[Study on clozapine treatment at the Charles Perrens Hospital in Bordeaux, 15 years after its marketing].Encephale. 2009 Sep; 35(4):321-9.E
The international consensus conferences concerning schizophrenia and the authorization to market (French AMM) reserve this molecule for the treatment of resistant schizophrenia. Resistant schizophrenia, as defined by the marketing authorisation, corresponds to the absence of improvement in a patient's state despite two successive treatments with antipsychotics, or at least an atypical drug at an adequate dose for a sufficient length of time.
Our investigation compares hospital practices to the marketing authorisation and guidelines regarding resistant schizophrenia.
All clozapine prescriptions delivered by the pharmacists at the Charles Perrens Hospital were recorded during the month of February 2007. General information concerning the patient and his or her treatment were collected, based on different support teams set up in the hospital. First, the hospital administrative program was used to manage the patients. Then, the treatment establishment form, filled out by psychiatrists before the beginning of the treatment, listed all previous treatments given to the patient and indicated any inefficacy or intolerances to prior treatments. Then, a program monitored the delivery of this molecule and finally, prescriptions were recorded to describe present treatment.
Our study consisted of 61 patients, mostly male subjects averaging 40 years of age, single, who had been under psychiatric care for about 15 years, and were, for the most part, professionally inactive. Clozapine was prescribed for schizophrenic (90%) and for bipolar patients (10%). Clozapine was also often prescribed for patients whose illness had not improved with prior treatments. The average dose was of 489 mg/day for patients considered stable, i.e., those for whom clozapine was prescribed with efficacy observed for a sufficiently long time. It was associated in 88% of all cases with another psychotropic: anxiolytic (68% of cases), normothymic (26% of cases), antidepressant (16%) and antipsychotic (42%).
In practice, clozapine seems to be efficient in bipolar disorders, although the marketing authorisation does not envisage this indication. It is never prescribed first, as some recommendations indicate, even though the follow-up of certain treatments does not always seem adequate to appreciate their non-effectiveness. Seldom prescribed alone, clozapine is often associated with another antipsychotic, a practice not favoured by many experts. Our investigation thus confirms the increase in co-prescriptions, particularly in hospital, for patients who have not improved with clozapine alone, a case that is barely taken into consideration in consensus conferences. With the lack of innovative molecules, psychiatrists are prompted to associate several antipsychotics, with the risk of supporting iatrogenic medication, whereas the experts reserve the relevance of such associations because of a lack of randomised studies.