wa clozapine initiation and titration chart. clozapine is well recognised as a high risk medication...
TRANSCRIPT
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WA Clozapine Initiation and Titration Chart
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Clozapine is well recognised as a high risk medication It was released in early 1970s and withdrawn from
market due to incidents of neutropenia, myocarditis and sudden death.
Re-introduced for use in Australia with stringent monitoring and guidance for use in conjunction with the Clozapine Monitoring System (Clopine Connect®)
Specialised chart developed for WA Health to co-ordinate management of clozapine.
This presentation will provide education on features, prompts and alerts in the chart.
Introduction
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Mental Health AIMS Reporting Medication Incidents (2007-2011)
Top 3 Medications Involved
Quetiapine 91
Clozapine 80
Paracetamol 79
Clonaz
epam
Clozap
ine
Codein
e
Diazep
am
Insu
lin
Lithiu
m
Lora
zepa
m
Met
form
in
Olanza
pine
Parac
etam
ol
Quetia
pine
Risper
idone
Sodium
Valp
roat
e
Temaz
epam
Venlaf
axine
0
10
20
30
40
50
60
70
80
90
100N
um
be
r o
f In
cid
en
ts
Clozapine is one of the top 3 medications involved in clinical incidents within mental health
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General Requirements
Chart to be completed for all in-patients initiated and re-titrated on clozapine
The National Inpatient Medication Chart MUST be annotated clearly to identify when a clozapine chart is in use
MEDICATION Chart No. ……….. Of ……………
□ IV/Fluid □ BGL/Insulin □ Acute Pain □ Other
□ Palliative Care □ Chemotherapy □ AnticoagulationClozapine chart
√
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Chart LayoutFront Page:
Patient Identification
Allergies and Adverse Drug Reactions
Pre-commencement documentation and checklist
Observations
•Temperature
•Pulse
•Blood pressure
•Respiratory rate
•Level of consciousness
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Chart Layout
Inside Page: (Opens into A3)
Dose Orders
Suggested Dosing Regimen
Monitoring
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Chart Layout
Back Page:
▪ Clozapine blood results monitoring system
▪ Guidelines for recommencing therapy after interruption
▪ Guidelines for blood test monitoring after interruption of therapy
▪ Alerts on side-effects associated with therapy
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Patient Identification
URMN:Family Name:Given Name:Address:
DOB: Sex M F
NOT A VALIDPRESCRIPTION UNLESS IDENTIFIERS PRESENT
First prescriber to print patient name and check label correct:………………………………………………………………………...…
√ Affix patient ID label or write information on pages 1 and 2 of chart
√ If using labels: First prescriber MUST HANDWRITE (PRINT) patient name and CHECK LABELS are correct
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Allergies & Adverse Reactions (ADR)
Adverse Drug Reaction
√ TICK BOX if patient has ‘Nil Known’ or ‘Unknown’ allergies or ADRs
√ If ADR exists, then affix ADR sticker to page 1 and document:
Drug name Reaction details Date of reaction Sign entry
Accurate information prevents harm from known ADRs
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Pre-commencement Screen
Pre-commencement Screen• A tick box to indicate if pre-commencement screen is required to be completed• A section to ensure a medical history is obtained from the patient• A checklist to ensure all pre-commencement clozapine requirements have been
completed
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Pre-commencement Screen
√ Complete “Clozapine checklist”. Prompts to: ▪ return completed ‘Clozapine Referral Form’ to a pharmacist ▪ check PBS eligibility ▪ consider continuation of supply ▪ provide ‘Clozapine Notification Form’; CMI and explain treatment ▪ obtain consent/second opinion ▪ obtain all Pre-Clozapine Baseline Tests within 10 days
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Preparation Prior to Initiation
√ All sections MUST BE completed and consultant to print name, sign and date
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Initial Observations
Record Baseline (Prior to 1st dose)
▪ Date ▪ Blood pressure
▪ Time ▪ Respiratory Rate
▪ Pulse
Careful observations to identify adverse events and respond appropriately
Record the first 7 days of observations • Temperature – Black • Pulse- Red• Blood Pressure (standing and lying)• Respiratory Rate• Level of Consciousness
After 7 days, continue observations with TPR & BP Chart
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Initial Observations
Prompts to identify when to notify a doctor who will be able to advise on whether to continue treatment
Prompts for frequency of monitoring
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Dose orders
Document: √ Formulation (suspension / tablets) √ Patient Clozapine Number √ Indication √ Weekly monitoring until : / /
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Dose orders
Clearly document: √ Date when medication started (Chart can accommodate 28 days) √ Prescriber PRINT name and sign √ Dose - morning (8:00) and/or night (20:00). Commence clozapine in the morning and
avoid weekends√ Nurse to double-sign each individual dose indicating dose checked and administered√ Drug level√ Pharmacy- To identify medication chart has been reviewed by pharmacist
Doses ONLY to be prescribed when approved by clozapine monitoring centre and patient clozapine number allocated
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Clozapine – Dosing Regimen
Quick reference for the suggested starting regimen for clozapine (Maudsley Prescribing Guidelines, 10th Ed)
This is ONLY a guide and dose titration should be individualised
Cautious titration and a divided dosage are necessary to minimise adverse events (e.g. hypotension, seizures,
sedation…)
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Monitoring Checklist
Complete all baseline measurements not more than 10 days of commencing clozapine. Date and document or √ tick the corresponding boxes
The following pre-clozapine baseline measurements must be completed within 10 days prior to commencing clozapine therapy: □ Blood group □ Troponin/ CK-MB□ Full physical examination □ Electrocardiogram (ECG)□ Pregnancy test (if applicable) □ Full blood Count
The following pre-clozapine baseline measurements are also recommended:
□ Smoking status □ Liver Function Test□ Weight □ Urea & Electrolyte□ Waist □ Fasting plasma glucose□ BMI □ Blood lipid□ Dietician review
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Monitoring Checklist
Space to document measurements for 28 days if required
Prompts for frequency of monitoring beyond first month of therapy.
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Haematological Monitoring▪ Regular full blood counts are required as clozapine can cause agranulocytosis▪ WBC and Neutrophil counts must be performed : -At least weekly for the first 18 weeks of therapy -At least every four weeks (28 days) after the first 18 weeks of therapy▪ Blood results are classified as green, amber or red
Classification of each colour and the recommended action
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Haematological Monitoring
POST-THERAPY BLOOD TESTING:
WEEKLY monitoring Patients on weekly monitoring at the time of discontinuation MUST continue to have 4 weeks of weekly monitoring
MONTHLY monitoring
Patients on monthly monitoring at the time of discontinuation MUST have one further test one month after discontinuation
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Recommendations for recommencing therapy after
interruption
Suggested Action: If clozapine is missed for > 48 hours, recommence at 12.5mg once or twice daily.
Re-titration of dose to therapeutic level depends on each individual and it may be
feasible to increase the dose more rapidly under supervision of the treating psychiatrist.
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Recommendations for Missed Doses
Different monitoring frequency is required when clozapine is missed for: < 72 hours > 72 hours but less than 4 weeks > 4 weeks
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Side-effects
• This is NOT a complete list of clozapine related side-effects
• Signs and symptoms of side-effects
• To increase awareness of possible side-effects
• Prompts for nurses to contact doctor if any of the side-effects are present
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Forms required for patient registration before initiation
▪ Before initiating clozapine, contact clinical pharmacist
▪ Forms that are still required to be completed:
»Clozapine Registration for New Patients Referral Form
(For registration of patient: Contact clinical pharmacist)
»Clozapine Notification Form /Consent Form
(Patient information)
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Summary▪ Baseline monitoring MUST be performed no more than
10 days before commencing treatment
▪ Clozapine MUST only be prescribed when patient is
allocated a clozapine number
▪ Current Clozapine Initiation Chart to be kept with other
medication charts
▪ Commence clozapine in the morning – avoid weekends
(preferable to start early in the week)
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Summary▪ Printed resources available from pharmacy: » Clozapine Registration for New Patients Referral Form
» Clozapine Counselling Points
» Clozapine Consumer Medication Information
▪ Please forward any comments on the Clozapine Chart to your clinical pharmacist or [email protected]
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