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Psychotic Decompensation After a Change to a Stabilized Medication prescriber altered the patient’s previously stable ensure their ability to consent to the change. For REFERENCES Institute for Safe Medication Practices Canada A KEY PARTNER IN Pharmacists and Community Pharmacy Teams medication regimen when fluvoxamine was some patients, especially those receiving REPORT MEDICATION INCIDENTS Online: www.ismp-canada.org/err_index.htm unavailable, which in turn led to an episode of • When a drug shortage is directly affecting patient psychiatric care, an advocate may be needed to 1. Schizophrenia. Toronto (ON): Centre for Addiction and Phone: 1-866-544-7672 decompensated psychosis. The patient required care, check all potential medication supply help with the process.13 Mental Health; [cited 2020 Oct 9]. Available from: https://www.camh.ca/en/health-info/mental-illness-and- admission to hospital for this episode. avenues. The Canadian Pharmacists Association’s addiction-index/schizophrenia Drug Shortages Guide presents a systematic Pharmacy and EMR Software Vendors 2. Remington G, Addington D, Honer W, Ismail Z, Raedler T, Functionality of Drug Interaction Software approach to assessing the impact of drug nonavail- Teehan M. Guidelines for the pharmacotherapy of ability and subsequent patient management. • Enhance drug interaction-checking software to schizophrenia in adults. Can J Psychiatry. 2017;62:604–616. It would be advantageous to expand the functionality • For any patient whose therapy will be affected by alert practitioners to the discontinuation of 3. Milliken HI. Schizophrenia and related psychotic disorders. Volume 21 • Issue 4 • April 22, 2021 In: RxTx [online resource]. Ottawa (ON): Canadian of software in pharmacy and EMR systems to alert a drug shortage, conduct a medication review. a medication linked to a clinically relevant, Pharmacists Association; [updated 2019 Sep 5; cited 2021 practitioners when changing a patient’s medication Discuss care options with prescribers. desirable interaction. Jan 14]. Available from: https://www.e-therapeutics.ca/search regimen (i.e., adding or discontinuing a medication) • Counsel patients and/or their caregivers about • Provide clinical decision support within the [subscription required to access content]. might affect an existing, clinically desirable drug substitute drug therapies and any potential interaction software, where possible. 4. Poudyal R, Lohani S. Clozapine associated pulmonary Psychotic Decompensation after a Change to a Stabilized embolism: systematic review. J Community Hosp Intern Med interaction. Such functionality could be further consequences of changing the regimen. Perspect. 2019;9(4):300-304. Medication Regimen enhanced with clinical decision support to promote • Add notes to the patient profile to communicate CONCLUSION 5. Jönsson AK, Schill J, Olsson H, Spigset O, Hägg S. Venous optimal prescribing and safe medication-use clinically significant information (such as an thromboembolism during treatment with antipsychotics: antipsychotic medication with known serious adverse practitioners, and the health care system as a whole. practices. intentional, desirable drug interaction) to other Learning from this death investigation illustrates the a review of current evidence. CNS Drugs. 2018;32:47-64. need to improve communication within the health 6. Sarvaiya N, Lapitskaya Y, Dima L, Manu P. Clozapine- years. This medication regimen stabilized the effects; because of these adverse effects, it is usually When a product is unavailable, for any reason, team members. associated pulmonary embolism: a high-mortality, dose- patient’s conditions. As a result of a shortage of reserved for managing schizophrenia that has proven pharmacists make efforts to obtain the needed supply In this case, the original prescriber had intentionally • Advise patients to keep an up-to-date medication care team, particularly by ensuring that all care independent and early-onset adverse effect. Am J Ther. • Conduct a medication review to help determine 2 fluvoxamine supply in the community, the prescriber resistant to treatment with other antipsychotic drugs. from different wholesalers, manufacturers, or other prescribed clozapine and fluvoxamine together to list and to maintain a record of why medication providers have access to medication history notes 2018;25(4):e434-e438. what, if any, therapeutic consequences may tapered the patient off fluvoxamine over a period of In particular, clozapine therapy puts patients at risk pharmacies and hospitals in their community. If the take advantage of the drug-drug interaction. More changes have been made in the past. The about treatment decisions. There is a need to develop 7. Clozaril [product monograph]. In: e-CPS. Ottawa (ON): result when changes to a medication regimen about a month, with a plan to initiate 2 alternative for granulocytopenia and agranulocytosis; product remains unavailable, despite these efforts, a specifically, concomitant therapy with the 2 drugs 5 Questions to Ask About Your Medications and protocols for changing therapy safely in high-risk Canadian Pharmacists Association; [updated 2020 Jan 23; are needed. cited 2021 Jan 3]. Available from: agents (both antidepressants with serotonergic consequently, patients must undergo regular blood substitute medication may be needed. allowed the patient’s conditions to be stabilized at a the MyMedRec app can help patients clarify, patients (i.e., by means of a full medication review). https://www.e-therapeutics.ca/search [subscription required • Improve software for checking drug interactions 3 properties) after discontinuation. During the tapering monitoring while taking this drug. Venous lower dose of clozapine, thus reducing not only the record and share this information with the health As well, there are opportunities to improve the to access content]. to alert prescribers and pharmacists to the period, the patient experienced psychotic thromboembolism, including fatal pulmonary When a new medication is being added to a patient’s risk of dose-related adverse effects, but also the pill care team. functionality of drug interaction–checking software 8. Canada Vigilance adverse reaction online database. Ottawa implications of eliminating a clinically relevant decompensation. embolism, is another adverse effect that has been medication profile, health care practitioners, burden. When a different prescriber (who may have (for alerting practitioners to the consequences of (ON): Health Canada; 2020 [searched 2020 Dec 30]. drug interaction through discontinuation of Available from: https://www.canada.ca/en/health-canada/ been unfamiliar with this interaction and its benefit) discontinuing specific medications) and to enhance reported with clozapine, as well as certain other including pharmacists and prescribers, use drug Prescribers services/drugs-health-products/medeffect-canada/adverse- a drug. 4-7 On the day the new medications were started, the antipsychotic drugs. For the period January 1965 to interaction–checking software in pharmacy and discontinued fluvoxamine because of the supply clinical decision support software (so as to promote reaction-database.html patient required admission to hospital for treatment of December 2020, the Canada Vigilance adverse electronic medical record (EMR) systems to support shortage, neither the pharmacy software nor the EMR • When medication therapy for a patient whose optimal care). 9. Selective serotonin reuptake inhibitors (SSRIs) [CPhA decompensated psychosis and symptoms suggestive reaction online database contains 188 case reports of identification of potential drug interactions.12 software flagged the clinical implications. condition has been stabilized by means of a monograph]. In: e-CPS. Ottawa (ON): Canadian Pharmacists of serotonin overload. Because the hospital still had a pulmonary embolism describing a serious outcome, Currently, such software does not have the multidrug regimen must be changed for a ACKNOWLEDGEMENTS Association; [revised 2019 Oct 19; cited 2021 Jan 3]. Available from: https://www.e-therapeutics.ca/search As part of an ongoing collaboration with a supply of fluvoxamine, this drug was restarted after including 81 fatal cases, in which clozapine functionality to alert practitioners to the therapeutic STRATEGIES TO IMPROVE MEDICATION SAFETY nonclinical reason, such as a drug shortage, [subscription required to access content]. 8 provincial death investigation service, ISMP Canada rapid discontinuation of the new agents. Additionally, administration was a suspected contributing factor. effect, if any, of discontinuing one of the interacting ensure that a medication review has been ISMP Canada gratefully acknowledges expert 10. Lu ML, Lane HY, Chen KP, Jann MW, Su MH, Chang WH. received a report describing an individual whose the doses of both fluvoxamine and clozapine were drugs, nor do such programs provide related clinical Recommendations to improve medication safety were conducted to identify any potential unintended review of this bulletin by the following individuals Fluvoxamine reduces the clozapine dosage needed in psychiatric conditions had been stabilized by a increased, in an effort to control the patient’s Fluvoxamine is an antidepressant and selective decision support. presented by the death investigation service. These effects (e.g., due to elimination of a known and (in alphabetical order): refractory schizophrenic patients. J Clin Psychiatry. included standardization of protocols for testing 2000;61(8):594-599. medication regimen that included both clozapine
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