Review Question - QID 105049

Clozapine is a highly effective atypical antipsychotic; however, due to the risk of agranulocytosis, it remains a second line treatment option best suited for treatment resistance (as in the above case) or patients with high risk of suicide.

The atypical antipsychotics are now considered first line in the treatment of schizophrenia due to their low side effect profile and better treatment of negative symptoms compared to the typical antipsychotics. The most effective of the atypical antipsychotics is clozapine; however, clozapine carries the dangerous risk of agranulocytosis. As a result, clozapine is reserved as a second line treatment and patients must be monitored with weekly blood draws for white blood cell count.

Kripke compared the effects of clozapine to other atypical antipsychotics in patients with schizophrenia and schizophrenia-like psychosis. In his review, he found that the attrition rate due to adverse effects was higher for clozapine than olanzapine or risperidone, as patients on clozapine experienced more blood dyscrasias, seizures, and weight gain; however, the attrition rate due to ineffectiveness was lower for clozapine than risperidone.

Capannolo et al. found that, in addition to the known side effect of agranulocytosis, clozapine inhibits interleukin-8-induced neutrophil chemotaxis. This impaired chemotaxis could predispose patients to infections.

Illustration A displays three of the most common side effects of atypical antipsychotics and arranges the drugs by how likely they are to produce those undesired effects.

Incorrect answers:
Answer 1: This patient has failed three trials of atypical antipsychotics. At this point, clozapine is more likely to be effective than aripiprazole.
Answer 2: The atypical antipsychotics are considered first line for treatment of schizophrenia due to their limited side effect profile compared to the typical antipsychotics. After failure of treatment with several atypical antipsychotics, a trial of clozapine may be effective.
Answer 4: Clonidine is not indicated for the initial treatment of schizophrenia.
Answer 5: Though cognitive behavioral therapy may eventually play a supplementary role in this patient's treatment, it is not indicated for the treatment of uncontrolled schizophrenia.