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Covid-19 may result in patients self-isolating and being unable to attend for their full blood counts or being reluctant to travel to clinics for sampling. Similarly there may be staffing issues that mean it becomes very difficult to maintain normal clinic approaches. In both instances a pragmatic approach is required that supports patient safety with regards to clozapine monitoring but also reflects the realities of the Covid-19 outbreak.
Given the current isolation advice this should support on-going dispensing in most instances.
Note: flu-like symptoms and a high temperature may suggest neutropenia so it is important to undertake a full blood count as soon as possible. It may be prudent to consider twice weekly monitoring whilst flu-like symptoms persist but this may prove impractical.
Clozapine supplies to patients must be maintained to prevent unnecessary treatment breaks and potential relapse. The following actions are recommended
Patients will be understandably anxious at this time providing appropriate reassurance may be necessary.
Patients should be advised to follow national guidance about self-isolation and other measures but also to contact mental health services for advice about blood testing.
There is no clear evidence regarding the impact of Covid-19 on clozapine plasma levels. A pragmatic approach is advised.
Twice weekly blood tests for amber results should be attempted but may be impractical and therefore consideration should be given to maintaining standard routine blood tests for amber results. Consideration of individual patient circumstances i.e. previous blood results history will be necessary.
Daily blood tests following a red result may also be impractical for community based patients. Consideration should be given to admitting all red alert patients to hospital to support the necessary blood testing.
Routine clozapine plasma levels should be temporarily suspended.
Undertaking additional plasma levels may be impractical and therefore clinical management of patients with pragmatic dose reductions is recommended.
Consideration should be given on a case by case basis to the benefits and risks of new starts and especially red re-challenges. Patients may be unwilling to come into hospital to start treatment and there may be a pressure to use beds for higher priorities.
Given the uncertain effects of Covid-19 on white blood cells it may be prudent to avoid exposing previously neutropenic patients to clozapine at this time.
Last reviewed: 24 March 2020
Next review: 24 March 2021
Author(s): Mental Health Pharmacy Services
Approved By: Mental Health Pharmacy Services
Reviewer Name(s): Andrew Walker, Suzanne Burke