There is no standardised protocol for the management of clozapine withdrawal syndrome following a red alert. This is one of the worst case scenarios with clozapine and it is not mentioned in the Maudsley guidelines1 or any other reliable guide. We have had 3 patients with a red alert in the past 9 months. They were doing very well on clozapine for 5,13 and 17 years respectively, with no previous amber or red alerts or significant side-effects. Since the acute withdrawal of clozapine one patient is not psychotic but not as alert or spontaneous as he was on clozapine, one has been acutely psychotic in hospital for 3 months and one is fragile but seems to be settling on aripiprazole.
A literature search revealed patchy reports of clozapine withdrawal syndrome but no consensus on what steps to take to reduce the relapse of psychosis, hospital admission and delirium or other acute physical illness following acute clozapine withdrawal.
Cholinergic rebound is a real possibility and the use of anticholinergics should be basic advice in this situation. Use of varying antipsychotics is the obvious second step.
We had two patients on anticholinergics and they had no major autonomic symptoms. The third patient is in hospital. An algorithm of what to do when faced with a red alert would be a useful addition to the psychiatric pharmacopeia.
References
- 1. Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry (Twelfth Edition). Wiley-Blackwell, 2015. [Google Scholar]