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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by Lamdage22 on February 23, 2015, at 9:10:15
I am thinking about switching to clozapine.
Are the heart issues reversible that can happen with clozapine?
What check ups should my doctor do to make sure my heart is ok while on clozapine?
THX
Posted by ed_uk2010 on February 23, 2015, at 12:26:03
In reply to Proper heart precautions with Clozapine, posted by Lamdage22 on February 23, 2015, at 9:10:15
Blood pressure, pulse and temperature will be monitored very frequently when the medication is first started. You will also have several blood tests performed before and during treatment. The most important, and most regular, is the complete blood count. You are likely to have an ECG before starting treatment, and one or more during treatment.
There are several cardiac issues with clozapine:
1. Sinus tachycardia (rapid heart rate) is very common. In most cases it is not serious. Less commonly, it can be caused by one of the more major heart conditions associated with clozapine, such as myocarditis.
2. Blood pressure changes are frequent. Low blood pressure, especially when standing up, is a common occurrence. Dizziness and weakness are symptoms. Raised blood pressure occurs less often.
3. Occasionally, clozapine causes a potentially serious heart condition called myocarditis. This refers to an inflammation of the heart muscle itself. Myocarditis normally happens in the first few weeks after clozapine is started. It is usually reversible if treatment is stopped as soon the diagnosis is suspected.
4. Cardiomyopathy. This is a disorder of the heart muscle which can occur, rarely, during long-term treatment.
.............
The risk of myocarditis is monitored by looking for symptoms such as increased heart rate + fever, breathlessness and chest pain. Fever, and especially increased heart rate, are common while on clozapine even when there is no myocarditis. Chest pain and breathlessness are much more suggestive of a serious problem. When the diagnosis is in doubt, additional tests are performed to assess for myocarditis.
Additional assessment may be needed in those with persistent and substantial heart rate elevations, normally with a fever, but +/- any cardiac symptoms. The additional tests may include....
1. An ECG to assess heart rate, rhythm and ST depression/elevation.
2. An additional blood count to look for increased or decreased white blood cells (of various types - the differential). A raised eosinophil count is suggestive of myocarditis. A raised white cell count in suggestive of infection/inflammation. A severely decreased white cell count is suggestive of a clozapine-induced blood disorder, with or without infection.
3. Blood tests for CRP (an inflammatory marker) and tropopin (a marker of heart muscle damage). Raised levels of both is highly suggestive of myocarditis. Some doctors monitor CRP and troponin before treatment and then once weekly for around four weeks - to detect myocarditis early. These blood tests can be done at the same time as the regular blood counts.
4. An echocardiogram (ultrasound scan of the heart) to look for signs of abnormal heart muscle movement/function. This is a specialist test.
5. A chest X-ray, mainly if other causes of chest pain and/or fever seem likely eg. pneumonia/infection.
Posted by Lamdage22 on February 25, 2015, at 6:01:02
In reply to Re: Proper heart precautions with Clozapine, posted by ed_uk2010 on February 23, 2015, at 12:26:03
Thanks, ED.
You are very knowledgeable.
So what you are saying is that i should get weekly blood tests checking the amount of white blood cells, eosinophil, CRP and troponin.
For how many weeks?
And weekly ECGs?
thx
Posted by ed_uk2010 on February 25, 2015, at 7:29:13
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 25, 2015, at 6:01:02
>So what you are saying is that i should get weekly blood tests checking the amount of white blood cells, eosinophil, CRP and troponin.
The white cell counts are an absolute requirement. The test includes eosinophils.
>For how many weeks?
The blood counts will continue weekly for quite a number of weeks before you would switch to less frequent testing. The requirements vary from country to country. I expect the requirements are the same in all European countries, as follows.....
The white cell count with a differential count must be monitored:
At least weekly for the first 18 weeks of treatment
At least at 2 week intervals between weeks 18 and 52
After 1 year of treatment with stable neutrophil counts, patients may be monitored at least at 4 week intervals
Monitoring must continue throughout treatment and for at least 4 weeks after discontinuation
>CRP and troponin.
These tests are potentially valuable, and you can ask about them. They are not essential however, and not all doctors perform them routinely. In general, if you doc does them, you would have a baseline test shortly before starting treatment and then one test per week for the first few weeks eg. the first 4 weeks, approx.
These tests are most useful if you have *symptoms* of myocarditis, in which case they should be performed as soon as the diagnosis is suspected.
>And weekly ECGs?
No. You would normally have one before starting treatment, unless you've had one very recently with no abnormalities. A repeat ECG may be performed after a few weeks of treatment. Otherwise, you only need one if there is a problem eg. a large heart rate increase which persists.
Hope this helps.
Posted by Lamdage22 on February 25, 2015, at 11:49:34
In reply to Re: Proper heart precautions with Clozapine » Lamdage22, posted by ed_uk2010 on February 25, 2015, at 7:29:13
Thanks ed.
I will only do it if crp and troponin are checked as well in the first 8 weeks.
I will tell my dr.
Posted by ed_uk2010 on February 25, 2015, at 18:53:55
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 25, 2015, at 11:49:34
Has your doctor suggested clozapine?
Clozapine is likely to cause more side effects than your current meds on a daily basis, but not necessarily so. Given that it will not solve your weight gain issue, and that you are responding (I think) to your current meds, do you definitely want to switch?
Posted by Lamdage22 on February 26, 2015, at 1:38:04
In reply to Re: Proper heart precautions with Clozapine » Lamdage22, posted by ed_uk2010 on February 25, 2015, at 18:53:55
I have akathisia at nighttime. Turning around hundreds of times, moving my legs.
Its unpleasant!
I am scared of movement disorders.
My dr suggestef.
Posted by ed_uk2010 on February 26, 2015, at 7:02:05
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 26, 2015, at 1:38:04
> I have akathisia at nighttime. Turning around hundreds of times, moving my legs.
>
> Its unpleasant!It's definitely unpleasant. Akathisia is often very dependent on dosage. I'm not surprised you have akathisia because your total antipsychotic dose is high. You could probably resolve this problem with a cautious dose reduction + the use of a non-antipsychotic for insomnia.
Alternatively, clozapine does not often cause movement disorders or akathisia (usually none). Clozapine does not even worsen Parkinson's disease! There is often a reduction in movement disorder symptoms when switching to clozapine from other antipsychotics. The reduction in symptoms caused by clozapine means that in people switched from other drugs, clozapine 'appears' to cause fewer movement problems than placebo.
Clozapine causes just as much weight gain as Zyprexa, so you would need to continue metformin.
On clozapine, you may require additional medications to reduce excessive saliva production (especially at night).
Are you more concerned about your weight or about movement problems?
Posted by Lamdage22 on February 26, 2015, at 8:44:18
In reply to Re: Proper heart precautions with Clozapine, posted by ed_uk2010 on February 26, 2015, at 7:02:05
Movement problems.
I dont expect carb cravings to be worse than they are now.
I could still up the Metformin to 2500.
Do you expect the cravings to be worse on clozapine only?
(Worse than now?)
Posted by ed_uk2010 on February 26, 2015, at 11:49:00
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 26, 2015, at 8:44:18
>Do you expect the cravings to be worse on clozapine only?
> (Worse than now?)Probably similar.
Posted by Lamdage22 on February 26, 2015, at 11:54:08
In reply to Re: Proper heart precautions with Clozapine » Lamdage22, posted by ed_uk2010 on February 26, 2015, at 11:49:00
Do you find my choice rational to switch to Clozapine until i can eventually be on cannabidiol?
Posted by ed_uk2010 on February 26, 2015, at 13:16:09
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 26, 2015, at 11:54:08
>Do you find my choice rational to switch to Clozapine until i can eventually be on cannabidiol?
I don't think you can easily compare clozapine and cannabidiol.
Clozapine is a very well established antipsychotic. It is highly likely to be effective for you, but it may cause side effects.
Cannabidiol shows potential, but it's only just being developed as a possible antipsychotic. It may or may not help you. It's not clear whether it could replace your current meds.
Posted by Lamdage22 on February 26, 2015, at 13:18:42
In reply to Re: Proper heart precautions with Clozapine, posted by ed_uk2010 on February 26, 2015, at 13:16:09
I know, ED.
Trying doesnt hurt though.
It will all be done in a slow manner so nobody has to worry.
Posted by Lamdage22 on February 27, 2015, at 9:49:10
In reply to Re: Proper heart precautions with Clozapine, posted by ed_uk2010 on February 23, 2015, at 12:26:03
Ed,
is cardiomyopathy reversible when it happens with clozapine?
Posted by ed_uk2010 on February 27, 2015, at 11:12:47
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 27, 2015, at 9:49:10
> Ed,
>
> is cardiomyopathy reversible when it happens with clozapine?Unlike myocarditis, which normally occurs early during treatment (less than 2 months), cardiomyopathy is generally reported to occur much later in treatment. Cardiomyopathy has a much more gradual onset. It has been reported in 1 out of every 1000 patients treated in Australia, and in 1 out of every 5000 patients treated in the UK. Early on, it may not cause symptoms, eventually - it can cause chronic heart failure.
Echocardiography (an ultrasound scan of the heart) every 6-12 months has been suggested as a way of monitoring for cardiomyopathy. It is not routine practice in the UK but I don't know about elsewhere.
If clozapine is stopped in time, cardiomyopathy is often at least partially reversible. If clozapine is continued, the disorder may progress and have a fatal outcome. As soon as cardiomyopathy is diagnosed, clozapine must be discontinued and medications prescribed to aid cardiac recovery eg. ACE inhibitors etc.
A relatively new blood test called B-type natriuretic peptide (BNP) may be useful to monitor and assess for cardiac dysfunction in those receiving clozapine. Increased levels of BNF show that the heart muscle is under abnormal stress.
Posted by Lamdage22 on February 28, 2015, at 5:50:49
In reply to Re: Proper heart precautions with Clozapine, posted by ed_uk2010 on February 27, 2015, at 11:12:47
Maybe i wont do much more than to replace Zyprexa with Clozapine.
I just want to cut down my TD risk and my tardive akathisia risk.
Then ill try CBD i think and see if i can take it or not. (Monitor immunosupression).
Im very undecided.
@Ed: Where did you get all that knowledge? You could work in the medical field. Or do you already?
Posted by Lamdage22 on March 3, 2015, at 4:58:46
In reply to Re: Proper heart precautions with Clozapine, posted by Lamdage22 on February 28, 2015, at 5:50:49
I have decided against clozapine...
The heart risks and a diabetes risk comparable to Zyprexa are too much for me. I think it is considered a last resort med for a reason.
I think Ed has provided a very comprehensive summary on heart risks with clozapine though and people can now google this.
Thanks.
This is the end of the thread.
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