Questions for pharmacist providers in clozapine clinics: Zacher

About 5 years. There was an established clozapine clinic when I started, so I took over.

I completed a Psychiatric Pharmacy Residency at the Louis Stokes Cleveland VAMC in 2004–2005. In 2006, I took the BCPP exam and became board certified in psychiatric pharmacy.

Since I coordinate all of the blood draws, and I monitor the results, I feel that I get to see the patients a lot more frequently than the providers, so for a lot of the patients, especially those with more severe psychosis, I also serve as a regular “social outing” which gets them out of the house and into the community. I have several patients who look forward to their clozapine appointments every month due to our interactions.

The majority of the patients at my facility are on monthly monitoring, so the clinic is only very active on the weeks when they are due for lab draws. On average, I probably spend about 2–3 hours per month devoted to clozapine. I am responsible for ordering all of the lab draws for the patients and making sure that they actually follow up and come in, so this involves working with several of the local group homes in our area where several of our patients live. Once the labs have been completed, I interpret the results. I see the majority of the patients at least monthly to assist in monitoring for efficacy and adverse effects, and the weekly and biweekly monitoring patients actually see me for their appointments most weeks and only follow up with the psychiatrist every few months. I am also responsible for filling out all of the paperwork and doing all initial education for clozapine new starts at our facility. It is also my responsibility to enter all of the clozapine orders into our pharmacy package, as we have restricted it so that it cannot be ordered electronically.

My clinic is billable, so any of the outpatients that come in to see me are billed for a pharmacist MTM visit. Currently, the workload is not captured for the inpatient lab monitoring that I am doing for our nursing home and acute psychiatry patients.

My favorite part of my service is actually the patients themselves. I get the most satisfaction from working with the severely mentally ill population. I have seen many patients who are very ill and completely impaired improve so much with the use of clozapine, and it really gives me a sense of purpose.

I am not currently involved in any clozapine-related research as we have a relatively small population at our facility, so it would not likely yield many clinically meaningful results.

First and foremost, I would recommend that anyone wanting to start up a clozapine clinic refresh themselves on the pharmacology of this drug and become very familiar with the FDA monitoring requirements. I also feel that it is really important to get to know the patients well individually before taking over the regular appointments, as these patients tend to take longer to build up trust with a provider than patients with other conditions. I also recommend coming up with a good filing system to keep track of paperwork and develop a good tracking system to assure that patients are having labs done in compliance with FDA guidelines.

I generally always have my residents or students sit in on individual visits with clozapine patients as I feel that many of them have not had exposure to patients that are this ill. I also often ask the patients to share their personal stories about their lives before and after clozapine, as I find that many trainees do not realize the positive impact that this medication has on the lives of many patients. Generally, we also review the VA specific paperwork that needs to be filled out and compare that to the manufacturer specific paperwork so that each trainee is aware of what to do if a clozapine patient walks into his or her pharmacy, regardless of what setting they are working in.

I would definitely recommend that anyone interested in working with clozapine refreshes on the original clinical trials by Kane et al. that got this medication approved initially. I would also recommend reviewing the InterSEPT trial looking at the protective effects against suicidal behaviors associated with this medication. Finally, I feel that all practitioners working with the medication should review the prescribing information, as the package insert very clearly lays out the many black box warnings associated with this medication as well as provides clear charts and diagrams about what to do in the event of abnormal CBC results and/or missed doses.