Questions for pharmacist providers in clozapine clinics: Mascarenas

I have been a clinical pharmacy specialist with the VA since 2003. When I first started, the clozapine procedures for our facility were not clear, including enrollment, transfer, and discontinuation, and the required monitoring was not being submitted to the VA's Clozapine Coordinating Center. I developed the clozapine clinic as a way to organize our system and to make sure our patients were being monitored properly. Eventually I became the clozapine treatment team co-chair for South Texas.

I worked for the VA in Infectious Diseases during my senior year in high school and all through undergraduate school. It was my first interaction with clinical pharmacy. The VA allowed pharmacists to exhibit significant autonomy, which seemed ideal.

I decided psychiatric pharmacy was my calling during my first intern rotation, with Jerry Overman in Outpatient Psychiatry at the VA. I am now in the position he created from the ground up. I stayed in San Antonio and completed a combined Psychiatric Pharmacy residency/Masters degree under Larry Ereshefsky, with some longitudinal clinics completed at the VA. I earned board certification in 2003.

I think increasing access to clozapine therapy at our facility. The VA has specific requirements and its own national regulatory board for clozapine therapy. Previously our local process was very complex and time-consuming, which greatly limited the number of patients initiated on clozapine. Now, new patients can be enrolled and provided a prescription within 2 hours.

Formal clozapine clinic is only one half-day of my work week. On that day I see 5–7 patients receiving clozapine therapy for medication management, including symptom monitoring, side effect monitoring and management, lab monitoring, and dosage adjustments. Some are on monthly monitoring, some are new starts. One day a month I verify all lab values have been submitted to our National Clozapine Coordinating Center.

I am on call to coordinate paperwork for any new starts and transfers in South Texas, including the VA application and informed consent form. I am also responsible for registering providers as clozapine prescribers.

The government handles that for us.

Interacting with the patients. It's the reason I chose psych pharmacy over infectious diseases.

I am a co-investigator on a Dual Diagnosis PTSD-alcohol dependence study as part of the STRONG*STAR consortium. I will also be working with our clinic psychologist on an adherence project, which is in the planning stages.

I would first meet with your doctors to see if there any specific issues you can help them with (i.e., access, lab monitoring, required visits, etc). From there you can develop a clinic that can focus on the facility's problem areas. I would recommend having a good relationship with your lab as well. Many of our patients come to clinic immediately after having lab done, and it really helps if the results are available quickly. Our lab is great about making sure the results are quickly posted, and if the order isn't entered, calling us to get it rather than sending the patient away. Also, having a procedure with your pharmacy is very helpful. Our outpatient pharmacy is great about quickly filling clozapine scripts, paging me with questions, and not accidentally mailing these prescriptions out.

I have students and residents perform mental status exams and assess for side effects on the very stable patients, which both patients and trainees enjoy. I also have them review lab results while in clinic. I have them help with informed consent when it comes up. They are also responsible to alert me should anyone receiving clozapine be admitted to inpatient, so that we can make sure the medication is continued.

Iqbal MM, Rahman A, Husain Z, et al. Clozapine: A Clinical Review of Adverse Effects and Management. Annals of Clinical Psychiatr 2003; 15(1):33–48.

Porcelli S, Balzarro B, Serretti A. Clozapine resistance: Augmentation strategies. Eur Neuropsychopharmacol 2011.