The utilisation rate of clozapine for treatment resistant schizophrenia within trustwide adult inpatient services over one year

Abstract

Aims. The audit was undertaken to explore if inpatients with treatment resistant schizophrenia (TRS), or whose condition has not adequately responded to two antipsychotics of an optimal duration and dose, were offered clozapine as per NICE guidelines (CG178 1.5.7.2). Methods. Data were collected retrospectively and anonymously from all electronic notes via the UK-CRIS analysis platform. The inclusion criteria required patients, aged 18-64 years, to have a schizophrenia (ICD10 F20) diagnosis and to have been admitted to one of ten Trust inpatient wards between 01/01/ 2020 and 01/01/2021. Patients were required to fulfil the criteria of treatment resistance, as having an inadequate response to two or more antipsychotic drugs, one of which was an atypical agent. Patients who had previously tried or were currently on clozapine were excluded. Those with non-schizophrenia psychotic disorders were also excluded. 347,645 records were electronically screened according to the criteria, and 209 records were reviewed. Results. 43 patients from the 209 patients reviewed were found to be eligible for clozapine. 28 (65%) were offered clozapine during their admission and 9 of these patients had started the titration process (21% of those eligible). Of the 19 patients who declined clozapine when offered, 14 had refused the drug with the most common reason of not accepting the required blood monitoring (n=10). Of the 15 eligible patients who were not offered clozapine, the clinical team had documented a consideration to offer clozapine in 6 patients (14%) but had rejected its, predominantly due to concerns of non-compliance. For 3 patients (7%) the clinical team considered for but did not offer clozapine. There was no documentation regarding clozapine for 6 patients (14%). Conclusion. This audit identified that most patients with TRS were offered clozapine during their admission. However, a proportion of patients were not offered the gold standard treatment for TRS and this may lead to poorer outcomes. It demonstrated that a minority of eligible patients ultimately start the drug. There are barriers for eligible patients to accept clozapine, for instance around the regular blood monitoring required.