Clinical impact of reducing the frequency of clozapine monitoring: Controlled mirror-image cohort study (Malhotra, 2023)

Oloyede E., Dzahini O., Abolou Z., Gee S., Whiskey E., Malhotra D., Hussain M., Osborne I., Casetta C., McGuire P., MacCabe J.H., Taylor D. 

British Journal of Psychiatry 2023;223(2): 382-388. 

Available online at this link 

Background To minimise infection during COVID-19, the clozapine haematological monitoring interval was extended from 4-weekly to 12-weekly intervals in South London and Maudsley NHS Foundation Trust. Aims To investigate the impact of this temporary policy change on clinical and safety outcomes. 

Method All patients who received clozapine treatment with extended (12-weekly) monitoring in a large London National Health Service trust were included in a 1-year mirror-image study. A comparison group was selected with standard monitoring. The proportion of participants with mild to severe neutropenia and the proportion of participants attending the emergency department for clozapine-induced severe neutropenia treatment during the follow-up period were compared. Psychiatric hospital admission rates, clozapine dose and concomitant psychotropic medication in the 1 year before and the 1 year after extended monitoring were compared. All-cause clozapine discontinuation at 1-year follow-up was examined. 

Results Of 569 participants, 459 received clozapine with extended monitoring and 110 controls continued as normal. The total person-years were 458 in the intervention group and 109 in the control group, with a median follow-up time of 1 year in both groups. During follow-up, two participants (0.4%) recorded mild to moderate neutropenia in the intervention group and one (0.9%) in the control group. There was no difference in the incidence of haematological events between the two groups (IRR = 0.48, 95% CI 0.02-28.15, P = 0.29). All neutropenia cases in the intervention group were mild, co-occurring during COVID-19 infection. The median number of admissions per patient during the pre-mirror period remained unchanged (0, IQR = 0) during the post-mirror period. There was one death in the control group, secondary to COVID-19 infection. 

Conclusions There was no evidence that the incidence of severe neutropenia was increased in those receiving extended monitoring.Copyright © The Author(s), 2023. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists.