Polypharmacy in clozapine-treated patients: A retrospective analysis of 667 patients in Ottawa, Canada.

BACKGROUND

Clozapine is the gold standard for treatment-resistant schizophrenia (TRS), yet only 40 % of patients respond. Clinicians often add other psychotropics despite limited evidence and possible harms. Canadian data on this practice remains sparse.

METHODS

We retrospectively reviewed charts of 667 adults prescribed clozapine between 2017-2020 in Ottawa, Canada. Clozapine augmentation was defined as prescription of ≥1 other psychotropic medication. Descriptive statistics summarized medication class frequences; X2 or Wilcoxon tests assessed associations with demographic and clinical variables.

RESULTS

After excluding four charts without medication data, 550/663 patients (83 %) received at least one add-on class (median 2 classes, IQR 1-3). Anti-psychotics were the commonest add-ons with 354 patients (53.4 % of all; 64.4 % of the augmented group) receiving clozapine plus another antipsychotic, most often aripiprazole (n=83). Valproate/divalproex was the commonest add-on (n=115). Clozapine with Paliperidone was the most frequent two-drug combination (n=29). Augmentation was more frequent in schizoaffective disorder than schizophrenia (91 vs. 81 %, p=0.010), in older adults (median 46 vs. 38 yrs, p<0.001), in females (88 vs. 81 %, p=0.028), and in patients with respiratory disease (p=0.015) or diabetes (p=0.019). Residence in supported or inpatient housing was also associated with augmentation (p<0.001). Recent hospitalization, current smoking, and self-reported ethnicity showed no association with augmentation (p≥0.33).

CONCLUSIONS

Clozapine polypharmacy is common in patients treated at this Canadian psychiatric hospital, with more than half of clozapine-treated patients receiving an additional antipsychotic. This high prevalence highlights a need for evidence-based guidelines and integrated monitoring to balance symptomatic benefit against additive pharmacologic risk in TRS.