Easy-to-read medicine information about clozapine – what it is, how to take it safely and possible side effects. Clozapine is also called Clopine or Clozaril.
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What is clozapine?
Clozapine is used to treat schizophrenia. It does not cure this condition, but is used to help ease the symptoms and help you on your recovery path. It can help improve symptoms such the experience of hearing voices (hallucinations), ideas that distress you and don't seem to be based in reality (delusions) and difficulty in thinking clearly (thought disorder).
Clozapine is used when people have tried at least 2 other antipsychotic medicines and found they did not work well enough or for people who have difficultly managing side effects with other antipsychotics.
Clozapine belongs to a group of medicines called antipsychotics. Read more about antipsychotic medication. In New Zealand, clozapine is available as tablets or a liquid.
The dose of clozapine is different for different people, depending on your response. Your doctor will start you on a low dose and increase it slowly as your body gets used to it. The following is a guide.
- Day 1: Start with 12.5 mg one or 2 times a day.
- Day 2: Increase to 25 mg one or 2 times a day.
- Over the following 2 to 3 weeks: Your dose would be increased gradually by 25–50 mg a day, until you are taking the dose that will give you the most benefit. This is usually 200–450 mg a day but can be up to a maximum of 900 mg per day.
- Dose increases may vary depending on your response to treatment and your medical history.
- After a while, your doctor might also recommend reducing your dose, depending on how you respond to clozapine.
- Always take your clozapine exactly as your doctor has told you.
- Do not stop taking clozapine without talking to your doctor first.
- The pharmacy label on your medicine will tell you how much clozapine to take, how often to take it and any special instructions.
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How to take clozapine
- Timing: Clozapine is usually taken 2 times a day. However, if your total daily dose is 200 mg or less, you may be able to take the whole amount in a single dose, usually in the evening. Try to take your clozapine dose at the same times each day. You can take clozapine with or without food. Swallow clozapine tablets with a full glass of water or other liquid. Liquid clozapine may be taken alone or in water. Shake the bottle for 10 seconds before use.
- Missed dose: If you forget to take your dose, take it as soon as you remember, if it is within 4–6 hours of when it was due. But if it is nearly time for your next dose, just take the next dose at the right time. Do not take double the dose. If you forget to take clozapine for more than 48 hours, you must contact your doctor or the clinic you normally attend. Your dose may need to be adjusted.
- Keep taking clozapine every day. It usually takes a few weeks to start working and it can take a few months before you feel the full benefits. Do not stop taking clozapine suddenly as your symptoms may return if you stop taking it too early. Talk to your doctor or nurse before stopping.
Avoid alcohol while you are taking clozapine, especially when you first start treatment. Drinking alcohol while taking clozapine can cause drowsiness and affect concentration, putting you at risk of falls and other accidents. It can also cause agitation, aggression and forgetfulness. If you do drink alcohol, drink only small amounts and see how you feel. Do not stop taking your medication.
Smoking (but not nicotine replacement therapy or vaping) affects the way your body breaks down (metabolises) clozapine. If you start smoking, or stop smoking while you are taking clozapine, tell your healthcare provider. Your dose of clozapine may need to be adjusted. If you wish to stop smoking while you are taking clozapine, your doctor can plan a smoking cessation programme with you and monitor your clozapine levels.
Don't change how much caffeine you have. Sources of caffeine include coffee, cola or energy drinks. Sudden changes in your caffeine intake can alter (increase or decrease) the levels of clozapine in your blood. This can be harmful.
Precautions – before starting clozapine
- Do you have any heart problems such as an irregular heartbeat or low blood pressure?
- Do you have Parkinson’s disease or epilepsy?
- Are you over 60 years old?
- Do you have diabetes or problems with high cholesterol?
- Do you smoke or have you recently stopped smoking?
- Do you have problems with constipation?
- Do you have problems with your liver or kidneys?
- Are you pregnant or breastfeeding?
- Are you taking any other medicines, including medicines you can buy without a prescription, such as herbal and complementary medicines?
If any of these apply, it’s important that you tell your doctor or pharmacist before you start clozapine. Sometimes a medicine isn’t suitable for a person with certain conditions, or it can only be used with extra care, which your pharmacist will tell you about.
Clozapine can affect your white blood cells called neutrophils. These cells help to fight infections and keep your immune system healthy.
- When clozapine causes a drop in the number of these cells, it leads to a condition called neutropenia. A more severe reduction in your white blood cells is called agranulocytosis. A drop in neutrophils puts you at greater risk of picking up infections.
- You need to get your white blood cell count checked with regular blood tests because you may not notice any symptoms until you have an infection.
- Checking the number of your white blood cells helps to find any changes before they cause problems.
- You will not be allowed to collect your clozapine prescription unless you have an up-to-date blood result.
- You will need to have a blood test within 10 days before starting clozapine treatment, then every week for the first 18 weeks of treatment. Then you will need to have blood tests every 4 weeks throughout treatment.
- Read more about neutropenia.
Clozapine may cause changes in your blood glucose level, cholesterol level and heart function. To check these things, your doctor will monitor your physical health. You will have your weight checked regularly. You may also need to have your liver, cholesterol and glucose levels checked. You will also have your blood pressure measured and may need an ECG test to check your heart rate.
Like all medicines, clozapine can cause side effects, although not everyone gets them. Often side effects improve as your body gets used to the new medicine.
Constipation is a very common side effect of clozapine (up to 8 in every 10 people taking clozapine). This can be very uncomfortable and if not treated, it can lead to serious problems. Most people starting clozapine will be prescribed laxatives.
- You can also prevent constipation by increasing the fluid and fibre intake in your diet and by exercising regularly. Most people will need to take laxatives. Read more about preventing constipation.
- If you have problems with constipation before starting clozapine, tell your doctor. You will be started on a laxative when you start taking clozapine.
- If you develop constipation while taking clozapine, contact your healthcare provider straight away for immediate treatment. Getting treatment as soon as possible is very important. These symptoms include:
- fewer bowel movements than usual or not having a bowel movement for 2 days or more
- hard or dry poos
- tummy pain
- bloating or gas in your tummy
- feeling sick (nausea) or being sick (vomiting)
- reduced appetite.
- diarrhoea (runny poos) can also be a symptom of constipation.
- You are at increased risk of constipation during the first 4 months of starting clozapine, if you have an increase in your clozapine dose, if you are taking other medicines that are likely to cause constipation, if your diet changes and if you are stopping smoking.
- Clozapine can affect your white blood cells which fight infection (a condition called neutropenia). This can put you at greater risk of picking up infections.
- At the first sign of infection (such as fever, cold or flu symptoms, muscle aches, headache, or sore throat) you need to contact your doctor or mental health worker for an urgent blood test to check your white blood cells.
- Read more about neutropenia.
Other side effects
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Clozapine interacts with a number of medicines and herbal supplements so check with your doctor or pharmacist before you take any other medicines.
The following links have more information on clozapine. Be aware that websites from other countries may contain information that differs from New Zealand recommendations.
- Important updates to clozapine data sheets and monitoring during COVID-19 pandemic Medsafe, NZ, 2020
- Clozapine: safe prescribing BPAC, NZ, 2017
- Safer prescribing of high-risk medicines: Clozapine. BPAC, NZ, 2014
- Clozapine: constipation Goodfellow Gems, NZ