Ensuring care for clozapine-treated schizophrenia patients during the COVID-19 pandemic

Abstract

The COVID-19 pandemic has posed considerable challenges in providing care for persons with schizophrenia. The ambulatory clinic of Comprehensive Recovery Service Line of the UPMC-Western Psychiatric Hospital serves around 1500 patients, nearly 1200 with psychotic disorders. When the COVID-19 National State of Emergency was declared (March 13th, 2020), safety precautions including social distancing efforts were rapidly implemented in our clinics on March 16 to prevent contagion-based transmission of the virus. While most visits were quickly converted to telehealth, the clozapine clinic and long acting antipsychotic injections necessitate in person encounters and are paramount for ensuring patient stability. Undeniably, clozapine is the best treatment for refractory schizophrenia, yet it remains significantly underutilized (Sarpal et al., 2019). Clozapine is associated with significantly better clinical outcomes compared to other antipsychotic medications, including fewer hospitalizations and improved social and community integration (Masuda et al., 2019). Of note, clozapine is the only medication in the USA dispensed with a “no blood, no drug” FDA mandate under the Clozapine Risk Evaluation and Mitigation Strategy (Clozapine REMS), requiring regular absolute neutrophil count (ANC) reporting. The rationale for this mandate is that clozapine is associated with a low prevalence yet potentially fatal risk of agranulocytosis. Under normal circumstances, hematologic monitoring decreases from every week after 6 months to every two weeks until one year, and then to every 4 weeks. Unless the regularly scheduled ANC is verified to be within a specified reference range, the pharmacists cannot dispense clozapine to the patient. Our clozapine clinic serves 184 patients; the majority (n = 165, 90%) are on monthly, nine on biweekly, and ten are on weekly ANC monitoring schedules. Under the care of several attending psychiatrists, in our clozapine clinic model, patients first see a phlebotomist, then have a structured visit with a nurse well versed in long-term clozapine management and receive clozapine at the adjoining pharmacy, if the ANC is verified by the pharmacist to be in the specified range. This integrated and efficient clozapine service has operated for 30 years. As information regarding COVID-19 transmission, morbidity and mortality rapidly emerged, we responded assertively and effectively to reassure concerned patients and their caregivers about our safety procedures. We changed clinic workflows to stagger appointments. Screening for COVID-19 symptoms, social distancing, and the use of personal protective equipment (PPE) have been previously detailed (Gannon et al., 2020). A plexiglass shield was added at the pharmacy counter, and pharmacy staff began to increasingly mail clozapine to patients or provide curbside pick-up to minimize contagion risks. As the pandemic progressed, on 3/22/2020, the FDA issued guidance that prescribers may use clinical judgement on whether the benefits of deferring laboratory monitoring (ANC) outweighs the risk of continuing clozapine treatment without an updated ANC. Given ANC exemptions, during the first week of April 2020 (Fig. 1 ), we permitted patients receiving clozapine for ≥1 year with normal ANCs and with no signs of infection to switch to telepsychiatry nurse visits; at the discretion of the attending physician, monthly ANC requirements were also relaxed upto every 3 months, consistent with a recent expert consensus statement (Siskind et al., 2020). Fig. 1 Fig. 1 The figure (bars) depicts rates of attendance at the clozapine clinic both before physical distancing measures, and during the pandemic, shown in 2-week intervals. Not unexpectedly, there was a significant shift from in person nursing visits to telepsychiatry nursing visits beginning the first week of April 2020 accompanied by a 23.5% drop in total nursing visits. Older patients were reticent to attend in person visits. Nurse visits comprise taking vitals, completing a mental status checklist, and monitoring clozapine side-effects, though vitals could not be completed via telepsychiatry. In view of the severe respiratory illnesses described with COVID-19 (Guan et al., 2020), in addition to fever, cough and shortness of breath, we were vigilant about clozapine-induced sialorrhea, sedation and aspiration which in turn can lead to pneumonia (de Leon et al., 2020). Whereas 13 patients (7%) had clozapine mailed to them prior to March 16, 2020, once the COVID-19 restrictions were in place, 51 patients (28%) had clozapine either mailed to them (n = 49) or picked up curbside (n = 2) (black stippled line in Fig. 1). Starting in early April through May 15, 2020, fifty patients (27%) had ANC monitoring exempted. At the time of writing (May 18, 2020), no clinical decompensation among our clozapine treated patients has occurred, and so far, only one patient has had a treatment gap for delayed pick-up of clozapine. What factors might account for our capacity to provide continued clozapine clinic services during the pandemic? First, thus far, the Pittsburgh region has not seen a surge of viral transmission. Second, and importantly, the long-established clozapine clinic and collocated pharmacy, with its low turnover of nursing and pharmacy staff, have built trusting relationships with patients, caregivers and psychiatrists. Additional factors may include rapid implementation of physical distancing, the use of PPE, mailing of clozapine, and finally, the rapid deployment of telepsychiatry nursing visits following authorization of ANC exemptions. Even though a small number of clozapine treated patients are served by our mobile medication nursing and Assertive Community Teams (ACT), these teams could not possibly provide in home support to all 184 patients attending our clozapine clinic. Moreover, we have not yet adopted the Point-of-Care ANC testing which might better support in home clozapine services. Data emerging from the COVID-19 pandemic could inform future examples of ANC exemptions, such as prolonged inclement weather, natural disasters, vacations, etc., and potentially even address whether long-term ANC monitoring could be safely reduced to less than every 4 weeks. Clozapine-associated severe neutropenia and mortality is negligible after one year (Myles et al., 2018). Nevertheless, in the context of the ongoing COVID-19 pandemic, the benefits of relaxing ANC monitoring must be weighed against the possibility that febrile neutropenia, pneumonia including acute respiratory distress syndrome and mortality could be associated with either clozapine treatment (de Leon et al., 2020) or viral infections including SARS-CoV-2 (Guan et al., 2020) or both. Sponsorship and sources of funding None. Declaration of competing interest None of the authors has any conflicts of interest with reference to this article.