Abstract
Background: Treatment refractory psychosis (TRP) involves severe, treatment-resistant symptoms and functional impairment, affecting about one-third of patients with psychotic illness. These patients often experience delayed identification and management. Clozapine, the most effective antipsychotic medication for TRP, is associated with longer life expectancy, lower relapse and fewer re-hospitalisations, but is associated with myocarditis, neutropaenia, metabolic issues and other adverse drug reactions (ADRs), complicating ongoing treatment. Some patients also continue to experience symptoms despite clozapine treatment.
Objectives: To enhance clinician confidence in identifying and managing TRP. It will provide updated guidance on initiating and optimising clozapine treatment, proactively managing ADRs (including metabolic effects), assessing risks like neutropaenia and myocarditis over time, and presenting monitoring protocols for rechallenging after clozapine-induced myocarditis or agranulocytosis. Additionally, non-pharmacotherapy augmentation strategies will be discussed.
Methods: We have synthesised current clinical guidelines and recent research, including meta-analyses, epidemiological studies, and clinical trials, to offer evidence- based recommendations for the care of patients with TRP.
Findings: Key findings include: (i) recent research enhances understanding of TRP and its management; (ii) personalised clozapine titration schedules can mitigate early ADRs; (iii) careful monitoring facilitates successful rechallenge with clozapine after adverse events; and (iv) clozapine augmentation allows for improved outcomes.
Conclusions: While clozapine is crucial for treating TRP, its use requires diligent monitoring due to potential ADRs. Personalised titration and adjunctive medications can enhance clozapine’s safety and efficacy, especially when rechallenging after serious ADRs. Most ADRs can be prevented or managed safely. Non-pharmacological therapies are also important in optimising TRP management.
Pre-congress workshop.