DRUGS & SUPPLEMENTS
1 INDICATIONS AND USAGE
Clozarem is an atypical antipsychotic indicated for:
1.1 Treatment-Resistant Schizophrenia
Clozarem is indicated for the treatment of severely ill patients with schizophrenia who fail to respond adequately to standard antipsychotic treatment. Because of the risks of severe neutropenia and of seizure associated with its use, Clozarem should be used only in patients who have failed to respond adequately to standard antipsychotic treatment [see Warnings and Precautions (5.1, 5.5) ].
The effectiveness of Clozarem in treatment-resistant schizophrenia was demonstrated in a 6-week, randomized, double-blind, active-controlled study comparing Clozarem and chlorpromazine in patients who had failed other antipsychotics .
1.2 Reduction in the Risk of Recurrent Suicidal Behavior in Schizophrenia or Schizoaffective Disorders
Clozarem is indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder who are judged to be at chronic risk for re-experiencing suicidal behavior, based on history and recent clinical state. Suicidal behavior refers to actions by a patient that put him/herself at risk for death.
The effectiveness of Clozarem in reducing the risk of recurrent suicidal behavior was demonstrated over a two-year treatment period in the InterSePT trial .
2 DOSAGE AND ADMINISTRATION
2.1 Required Laboratory Testing Prior to Initiation and During Therapy
Prior to initiating treatment with Clozarem, a baseline ANC must be obtained. The baseline ANC must be at least 1500/µL for the general population, and at least 1000/µL for patients with documented Benign Ethnic Neutropenia (BEN). To continue treatment, the ANC must be monitored regularly .
2.2 Dosing Information
The starting dose is 12.5 mg once daily or twice daily. The total daily dose can be increased in increments of 25 mg to 50 mg per day, if well-tolerated, to achieve a target dose of 300 mg to 450 mg per day by the end of 2 weeks. Subsequently, the dose can be increased once weekly or twice weekly, in increments of up to 100 mg. The maximum dose is 900 mg per day. To minimize the risk of orthostatic hypotension, bradycardia, and syncope, it is necessary to use this low starting dose, gradual titration schedule, and divided dosages [see Warnings and Precautions (5.3) ].
2.3 Important Administration Instructions
Clozarem Oral Suspension is administered to the mouth by the oral syringes provided (1 mL or 9 mL). After shaking the bottle for 10 seconds prior to each use, the syringe adaptor is pressed on top of the bottle. The oral syringe (1 mL or 9 mL) is filled with air, and inserted into the adaptor. The air is dispelled into the bottle and then the bottle is turned upside down. The prescribed amount of the suspension is drawn from the bottle and dispensed directly to the mouth. The prescribed dose should be administered immediately after it is prepared. Do not draw a dose and store it in the syringe for later use. After use, the oral syringe may be washed with warm water and dried for next use. The bottle may be closed with the same cap without removing the bottle adaptor. Educate patients and caregivers on the steps to administer Clozarem as described in the Patient Instructions for Use.
Clozarem can be taken with or without food .
2.4 Maintenance Treatment
Generally, patients responding to Clozarem should continue maintenance treatment on their effective dose beyond the acute episode.
2.5 Discontinuation of Treatment
Method of treatment discontinuation will vary depending on the patient's last ANC:
2.6 Re-Initiation of Treatment
When restarting Clozarem in patients who have discontinued Clozarem (i.e., 2 days or more since the last dose), re-initiate with 12.5 mg once daily or twice daily. This is necessary to minimize the risk of hypotension, bradycardia, and syncope . If that dose is well tolerated, the dose may be increased to the previously therapeutic dose more quickly than recommended for initial treatment.
2.7 Dosage Adjustments with Concomitant use of CYP1A2, CYP2D6, CYP3A4 Inhibitors or CYP1A2, CYP3A4 Inducers
Dose adjustments may be necessary in patients with concomitant use of: strong CYP1A2 inhibitors ; moderate or weak CYP1A2 inhibitors (e.g., oral contraceptives, or caffeine); CYP2D6 or CYP3A4 inhibitors (e.g., cimetidine, escitalopram, erythromycin, paroxetine, bupropion, fluoxetine, quinidine, duloxetine, terbinafine, or sertraline); CYP3A4 inducers (e.g., phenytoin, carbamazepine, St. John’s wort, and rifampin); or CYP1A2 inducers (e.g., tobacco smoking) (Table 1) .
Table 1: Dose Adjustment in Patients Taking Concomitant Medications
2.8 Renal or Hepatic Impairment, or CYP2D6 Poor Metabolizers
It may be necessary to reduce the Clozarem dose in patients with significant renal or hepatic impairment, or in CYP2D6 poor metabolizers [see Use in Specific Populations (8.6, 8.7) ].
3 DOSAGE FORMS AND STRENGTHS
Clozarem is available as a free-flowing yellow oral suspension. Each mL contains 50 mg of Clozarem.
Clozarem is contraindicated in patients with a history of serious hypersensitivity to Clozarem (e.g., photosensitivity, vasculitis, erythema multiforme, or Stevens-Johnson Syndrome) or any other component of Clozarem .
5 WARNINGS AND PRECAUTIONS
5.1 Severe Neutropenia
Clozarem can cause neutropenia (a low absolute neutrophil count [ANC]), defined as a reduction below pre-treatment normal levels of blood neutrophils. The ANC is usually available as a component of the complete blood count (CBC), including differential, and is more relevant to drug-induced neutropenia than is the white blood cell (WBC) count. The ANC may also be calculated using the following formula: ANC equals the Total WBC count multiplied by the total percentage of neutrophils obtained from the differential (neutrophil “segs” plus neutrophil “bands”). Other granulocytes (basophils and eosinophils) contribute minimally to neutropenia and their measurement is not necessary [see Adverse Reactions (6.2) ]. Neutropenia may be mild, moderate, or severe. To improve and standardize understanding, “severe neutropenia” replaces the previous terms severe leukopenia, severe granulocytopenia, or agranulocytosis.
Severe neutropenia, ANC less than (<) 500/µL, occurs in a small percentage of patients taking Clozarem and is associated with an increase in the risk of serious and potentially fatal infections. Risk of neutropenia appears greatest during the first 18 weeks on treatment and then declines. The mechanism by which Clozarem causes neutropenia is unknown and is not dose-dependent.
Two separate management algorithms are provided below, the first for patients in the general population, and the second for patients identified to have baseline neutropenia.
Clozarem Treatment and Monitoring in the General Patient Population
Obtain a CBC, including the ANC value, prior to initiating treatment with Clozarem to ensure the presence of a normal baseline neutrophil count (equal to or greater than 1500/µL) and to permit later comparisons. Patients in the general population with an ANC equal to or greater than (≥) 1500/µL are considered within normal range (Table 2) and are eligible to initiate treatment. Weekly ANC monitoring is required for all patients during the first 6 months of treatment. If a patient's ANC remains equal to or greater than 1500/µL for the first 6 months of treatment, monitoring frequency may be reduced to every 2 weeks for the next 6 months. If the ANC remains equal to or greater than 1500/µL for the second 6 months of continuous therapy, ANC monitoring frequency may be reduced to once every 4 weeks thereafter.
Table 2: Clozarem Treatment Recommendations Based on Absolute Neutrophil Count (ANC) Monitoring for the General Patient Population
* Confirm all initial reports of ANC less than 1500/µL with a repeat ANC measurement within 24 hours
** If clinically appropriate
Clozarem Treatment and Monitoring in Patients with Benign Ethnic Neutropenia
Benign ethnic neutropenia (BEN) is a condition observed in certain ethnic groups whose average ANC values are lower than “standard” laboratory ranges for neutrophils. It is most commonly observed in individuals of African descent (approximate prevalence of 25-50%), some Middle Eastern ethnic groups, and in other non-Caucasian ethnic groups with darker skin. BEN is more common in men. Patients with BEN have normal hematopoietic stem-cell number and myeloid maturation, are healthy, and do not suffer from repeated or severe infections. They are not at increased risk for developing VERSACLOZ-induced neutropenia. Additional evaluation may be needed to determine if baseline neutropenia is due to BEN. Consider hematology consultation before initiating or during Clozarem treatment as necessary.
Patients with BEN require a different ANC algorithm for Clozarem management due to their lower baseline ANC levels. Table 3 provides guidelines for managing Clozarem treatment and ANC monitoring in patients with BEN.
Table 3: Patients with Benign Ethnic Neutropenia (BEN); Clozarem Treatment Recommendations Based on Absolute Neutrophil Count (ANC) Monitoring
* Confirm all initial reports of ANC less than 1500/µL with a repeat ANC measurement within 24 hours
** If clinically appropriate
General Guidelines for Management of All Patients with Fever or with Neutropenia
Rechallenge after an ANC less than 500/µL (severe neutropenia)
For some patients who experience severe VERSACLOZ-related neutropenia, the risk of serious psychiatric illness from discontinuing Clozarem treatment may be greater than the risk of rechallenge (e.g., patients with severe schizophrenic illness who have no treatment options other than Clozarem). A hematology consultation may be useful in deciding to rechallenge a patient. In general, however, do not rechallenge patients who develop severe neutropenia with Clozarem or a Clozarem product.
If a patient will be rechallenged, the clinician should consider thresholds provided in Tables 2 and 3, the patient's medical and psychiatric history, a discussion with the patient and his/her caregiver about the benefits and risks of Clozarem rechallenge, and the severity and characteristics of the neutropenic episode.
Using Clozarem with Other Drugs Associated with Neutropenia
It is unclear if concurrent use of other drugs known to cause neutropenia increases the risk or severity of VERSACLOZ-induced neutropenia. There is no strong scientific rationale to avoid Clozarem treatment in patients concurrently treated with these drugs. If Clozarem is used concurrently with an agent known to cause neutropenia (e.g., some chemotherapeutic agents), consider monitoring patients more closely than the treatment guidelines provided in Tables 2 and 3. Consult with the treating oncologist in patients receiving concomitant chemotherapy.
5.2 Clozarem REMS Program
Clozarem is only available through a restricted program under a REMS called the Clozarem REMS Program because of the risk of severe neutropenia.
Notable requirements of the Clozarem REMS Program include:
Further information is available at www.clozapinerems.com or 1-844-267-8678.
5.3 Orthostatic Hypotension, Bradycardia, and Syncope
Hypotension, bradycardia, syncope, and cardiac arrest have occurred with Clozarem treatment. The risk is highest during the initial titration period, particularly with rapid dose-escalation. These reactions can occur with the first dose, at doses as low as 12.5 mg. These reactions can be fatal. The syndrome is consistent with neurally mediated reflex bradycardia.
Treatment must begin at a maximum dose of 12.5 mg once daily or twice daily. The total daily dose can be increased in increments of 25 mg to 50 mg per day, if well-tolerated, to a target dose of 300 mg to 450 mg per day (administered in divided doses) by the end of 2 weeks. Subsequently, the dose can be increased weekly or twice weekly, in increments of up to 100 mg. The maximum dose is 900 mg per day. Use cautious titration and a divided dosage schedule to minimize the risk of serious cardiovascular reactions . Consider reducing the dose if hypotension occurs. When restarting patients who have had even a brief interval off Clozarem (i.e., 2 days or more since the last dose), re-initiate treatment at 12.5 mg once daily or twice daily .
Use Clozarem cautiously in patients with cardiovascular disease (history of myocardial infarction or ischemia, heart failure, or conduction abnormalities), cerebrovascular disease, and conditions which would predispose patients to hypotension (e.g., concomitant use of antihypertensives, dehydration and hypovolemia).
Clozarem may cause somnolence, postural hypotension, and motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries. For patients with diseases, conditions, or medications that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic treatment.
Seizure has been estimated to occur in association with Clozarem use at a cumulative incidence at one year of approximately 5%, based on the occurrence of one or more seizures in 61 of 1743 patients exposed to Clozarem during its clinical testing prior to domestic marketing. The risk of seizure is dose-related. Initiate treatment with a low dose (12.5 mg), titrate slowly, and use divided dosing.
Use caution when administering Clozarem to patients with a history of seizures or other predisposing risk factors for seizure (e.g., head trauma or other CNS pathology, use of medications that lower the seizure threshold, or alcohol abuse). Because of the substantial risk of seizure associated with Clozarem use, caution patients about engaging in any activity where sudden loss of consciousness could cause serious risk to themselves or others (e.g., driving an automobile, operating complex machinery, swimming, climbing).
5.6 Myocarditis and Cardiomyopathy
Myocarditis and cardiomyopathy have occurred with the use of Clozarem. These reactions can be fatal. Discontinue Clozarem and obtain a cardiac evaluation upon suspicion of myocarditis or cardiomyopathy. Generally, patients with a history of clozapine-associated myocarditis or cardiomyopathy should not be rechallenged with Clozarem. However, if the benefit of Clozarem treatment is judged to outweigh the potential risks of recurrent myocarditis or cardiomyopathy, the clinician may consider rechallenge with Clozarem in consultation with a cardiologist, after a complete cardiac evaluation, and under close monitoring.
Consider the possibility of myocarditis or cardiomyopathy in patients receiving Clozarem who present with chest pain, dyspnea, persistent tachycardia at rest, palpitations, fever, flu-like symptoms, hypotension, other signs or symptoms of heart failure, or electrocardiographic findings (low voltages, ST-T abnormalities, arrhythmias, right axis deviation, and poor R wave progression). Myocarditis most frequently presents within the first two months of Clozarem treatment. Symptoms of cardiomyopathy generally occur later than clozapine-associated myocarditis and usually after 8 weeks of treatment. However, myocarditis and cardiomyopathy can occur at any period during treatment with Clozarem. It is common for nonspecific flu-like symptoms such as malaise, myalgia, pleuritic chest pain, and low-grade fevers to precede more overt signs of heart failure. Typical laboratory findings include elevated troponin I or T, elevated creatinine kinase-MB, peripheral eosinophilia, and elevated C-reactive protein (CRP). Chest roentgenogram may demonstrate cardiac silhouette enlargement, and cardiac imaging (echocardiogram, radionucleotide studies, or cardiac catheterization) may reveal evidence of left ventricular dysfunction.
5.7 Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials, largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality in this population. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Clozarem is not approved for the treatment of patients with dementia-related psychosis .
Eosinophilia, defined as a blood eosinophil count of greater than 700/μL, has occurred with Clozarem treatment. In clinical trials, approximately 1% of patients developed eosinophilia. Clozapine-related eosinophilia usually occurs during the first month of treatment. In some patients, it has been associated with myocarditis, pancreatitis, hepatitis, colitis, and nephritis. Such organ involvement could be consistent with a drug reaction with eosinophilia and systemic symptoms syndrome (DRESS), also known as drug induced hypersensitivity syndrome (DIHS). If eosinophilia develops during Clozarem treatment, evaluate promptly for signs and symptoms of systemic reactions, such as rash or other allergic symptoms, myocarditis, or other organ-specific disease associated with eosinophilia. If clozapine-related systemic disease is suspected, discontinue Clozarem immediately.
If a cause of eosinophilia unrelated to Clozarem is identified (e.g., asthma, allergies, collagen vascular disease, parasitic infections, and specific neoplasms), treat the underlying cause and continue Clozarem.
Clozapine-related eosinophilia has also occurred in the absence of organ involvement and can resolve without intervention. There are reports of successful rechallenge after discontinuation of Clozarem, without recurrence of eosinophilia. In the absence of organ involvement, continue Clozarem under careful monitoring. If the total eosinophil count continues to increase over several weeks in the absence of systemic disease, the decision to interrupt Clozarem therapy and rechallenge after the eosinophil count decreases should be based on the overall clinical assessment, in consultation with an internist or hematologist.
5.9 QT Interval Prolongation
QT prolongation, Torsades de Pointes and other life-threatening ventricular arrhythmias, cardiac arrest, and sudden death have occurred with Clozarem treatment. When prescribing Clozarem, consider the presence of additional risk factors for QT prolongation and serious cardiovascular reactions. Conditions that increase these risks include the following: history of QT prolongation, long QT syndrome, family history of long QT syndrome or sudden cardiac death, significant cardiac arrhythmia, recent myocardial infarction, uncompensated heart failure, treatment with other medications that cause QT prolongation, treatment with medications that inhibit the metabolism of Clozarem, and electrolyte abnormalities.
Prior to initiating treatment with Clozarem, perform a careful physical examination, medical history, and concomitant medication history. Consider obtaining a baseline ECG and serum chemistry panel. Correct electrolyte abnormalities. Discontinue Clozarem if the QTc interval exceeds 500 msec. If patients experience symptoms consistent with Torsades de Pointes or other arrhythmias,, obtain a cardiac evaluation and discontinue Clozarem.
Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of Clozarem. Drugs that cause QT prolongation include: specific antipsychotics (e.g., ziprasidone, iloperidone, chlorpromazine, thioridazine, mesoridazine, droperidol, pimozide), specific antibiotics (e.g., erythromycin, gatifloxacin, moxifloxacin, sparfloxacin), Class 1A antiarrhythmic medications (e.g., quinidine, procainamide) or Class III antiarrhythmic (e.g., amiodarone, sotalol), and others (e.g., pentamidine, levomethadyl acetate, methadone, halofantrine, mefloquine, dolasetron mesylate, probucol or tacrolimus). Clozarem is primarily metabolized by CYP isoenzymes 1A2, 2D6, and 3A4. Concomitant treatment with inhibitors of these enzymes can increase the concentration of Clozarem .
Hypokalemia and hypomagnesemia increase the risk of QT prolongation. Hypokalemia can result from diuretic therapy, diarrhea, and other causes. Use caution when treating patients at risk for significant electrolyte disturbance, particularly hypokalemia. Obtain baseline measurements of serum potassium and magnesium levels, and periodically monitor electrolytes. Correct electrolyte abnormalities before initiating treatment with Clozarem.
5.10 Metabolic Changes
Atypical antipsychotic drugs, including Clozarem, have been associated with metabolic changes that can increase cardiovascular and cerebrovascular risk. These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain. While atypical antipsychotic drugs may produce some metabolic changes, each drug in the class has its own specific risk profile.
Hyperglycemia and Diabetes Mellitus
Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics including Clozarem. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse reactions is not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent, hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycemia-related adverse reactions in patients treated with atypical antipsychotics are not available.
Patients with an established diagnosis of diabetes mellitus who are started on Clozarem should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug.
In a pooled data analysis of 8 studies in adult subjects with schizophrenia, the mean changes in fasting glucose concentration in the Clozarem and chlorpromazine groups were +11 mg/dL and +4 mg/dL respectively. A higher proportion of the Clozarem group demonstrated categorical increases from baseline in fasting glucose concentrations, compared to the chlorpromazine group (Table 4). The Clozarem doses were 100-900 mg per day (mean modal dose: 512 mg per day). The maximum chlorpromazine dose was 1800 mg per day (mean modal dose: 1029 mg per day). The median duration of exposure was 42 days for Clozarem and chlorpromazine.
Table 4: Categorical Changes in Fasting Glucose Level in Studies in Adult Subjects with Schizophrenia
Undesirable alterations in lipids have occurred in patients treated with atypical antipsychotics, including Clozarem. Clinical monitoring, including baseline and periodic follow-up lipid evaluations in patients using Clozarem, is recommended.
In a pooled data analysis of 10 studies in adult subjects with schizophrenia, Clozarem treatment was associated with increases in serum total cholesterol. No data were collected on LDL and HDL cholesterol. The mean increase in total cholesterol was 13 mg/dL in the Clozarem group and 15 mg/dL in the chlorpromazine group. In a pooled data analysis of 2 studies in adult subjects with schizophrenia, Clozarem treatment was associated with increases in fasting serum triglyceride. The mean increase in fasting triglyceride was 71 mg/dL (54%) in the Clozarem group and 39 mg/dL (35%) in the chlorpromazine group (Table 5). In addition, Clozarem treatment was associated with categorical increases in serum total cholesterol and triglyceride, as illustrated in Table 6. The proportion of patients with categorical increases in total cholesterol or fasting triglyceride increased with the duration of exposure. The median duration of Clozarem and chlorpromazine exposure was 45 days and 38 days, respectively. The Clozarem dose range was 100 mg to 900 mg daily; the maximum chlorpromazine dose was 1800 mg daily.
Table 5: Mean Changes in Total Cholesterol and Triglyceride Concentration in Studies in Adult Subjects with Schizophrenia
Table 6: Categorical Changes in Lipid Concentrations in Studies in Adult Subjects with Schizophrenia
Weight gain has occurred with the use of antipsychotics, including Clozarem. Monitor weight during treatment with Clozarem. Table 7 summarizes the data on weight gain by the duration of exposure pooled from 11 studies with Clozarem and active comparators. The median duration of exposure was 609, 728, and 42 days, in the Clozarem, olanzapine, and chlorpromazine group, respectively.
Table 7: Mean Change in Body Weight (kg) by duration of exposure from studies in adult subjects with schizophrenia
Table 8 summarizes pooled data from 11 studies in adult subjects with schizophrenia demonstrating weight gain ≥7% of body weight relative to baseline. The median duration of exposure was 609, 728, and 42 days, in the Clozarem, olanzapine, and chlorpromazine group, respectively.
Table 8: Proportion of adult subjects in schizophrenia studies with weight gain ≥7% relative to baseline body weight
5.11 Neuroleptic Malignant Syndrome
Antipsychotic drugs including Clozarem can cause a potentially fatal symptom complex referred to as Neuroleptic Malignant Syndrome. Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias). Associated findings can include elevated creatine phosphokinase (CPK), myoglobinuria, rhabdomyolysis, and acute renal failure.
The diagnostic evaluation of patients with this syndrome is complicated. It is important to consider the presence of other serious medical conditions (e.g., severe neutropenia, infection, heat stroke, primary CNS pathology, central anticholinergic toxicity, extrapyramidal symptoms, and drug fever).
The management of NMS should include (1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy, (2) intensive symptomatic treatment and medical monitoring, and (3) treatment of co-morbid medical conditions. There is no general agreement about specific pharmacological treatments for NMS.
If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. NMS can recur. Monitor closely if restarting treatment with antipsychotics.
NMS has occurred with Clozarem monotherapy and with concomitant CNS-active medications, including lithium.
Severe, life threatening, and in some cases fatal hepatotoxicity including hepatic failure, hepatic necrosis, and hepatitis have been reported in patients treated with Clozarem [see Adverse Reactions (6.2)
During Clozarem therapy, patients have experienced transient, clozapine-related fever. The peak incidence is within the first 3 weeks of treatment. While this fever is generally benign and self-limited, it may necessitate discontinuing treatment. The fever can be associated with an increase or decrease in WBC count. Carefully evaluate patients with fever to rule out severe neutropenia or infection. Consider the possibility of NMS [see Warnings and Precautions ].
5.14 Pulmonary Embolism
Pulmonary embolism and deep vein thrombosis have occurred in patients treated with Clozarem. Consider the possibility of pulmonary embolism in patients who present with deep vein thrombosis, acute dyspnea, chest pain, or with other respiratory signs and symptoms. Whether pulmonary embolus and deep vein thrombosis can be attributed to Clozarem or some characteristic(s) of patients is not clear.
5.15 Anticholinergic Toxicity
Clozarem has potent anticholinergic effects. Treatment with Clozarem can result in CNS and peripheral anticholinergic toxicity. Use with caution in the presence of narrow-angle glaucoma, concomitant anticholinergic medications, prostatic hypertrophy, or other conditions in which anticholinergic effects can lead to significant adverse reactions.
Treatment with Clozarem can result in gastrointestinal adverse reactions, including constipation, intestinal obstruction, fecal impaction, and paralytic ileus. Such reactions can be fatal. Constipation should be initially treated by ensuring adequate hydration and use of ancillary therapy such as bulk laxatives. Consultation with a gastroenterologist is advisable in more serious cases.
5.16 Interference with Cognitive and Motor Performance
Clozarem can cause sedation and impairment of cognitive and motor performance. Caution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that Clozarem does not affect them adversely. These reactions may be dose-related. Consider reducing the dose if they occur.
5.17 Tardive Dyskinesia
Tardive dyskinesia has occurred in patients treated with antipsychotic drugs, including Clozarem. The syndrome consists of potentially irreversible, involuntary, dyskinetic movements. The risk of TD and the likelihood that it will become irreversible are believed to increase with greater durations of treatment and higher total cumulative doses. However, the syndrome can develop after relatively brief treatment periods at low doses. Prescribe Clozarem in a manner that is most likely to minimize the risk of developing TD. Use the lowest effective dose and the shortest duration necessary to control symptoms. Periodically assess the need for continued treatment. Consider discontinuing treatment if TD occurs. However, some patients may require treatment with Clozarem despite the presence of the syndrome.
There is no known treatment for TD. However, the syndrome may remit partially or completely if treatment is discontinued. Antipsychotic treatment, itself, may suppress (or partially suppress) the signs and symptoms, and it has the potential to mask the underlying process. The effect of symptom suppression on the long-term course of TD is unknown.
5.18 Cerebrovascular Adverse Reactions
In controlled trials, elderly patients with dementia-related psychosis treated with some atypical antipsychotics had an increased risk (compared to placebo) of cerebrovascular adverse reactions (e.g., stroke, transient ischemic attack), including fatalities. The mechanism for this increased risk is not known. An increased risk cannot be excluded for Clozarem or other antipsychotics or other patient populations. Clozarem should be used with caution in patients with risk factors for cerebrovascular adverse reactions.
5.19 Recurrence of Psychosis and Cholinergic Rebound after Abrupt Discontinuation of Clozarem
If abrupt discontinuation of Clozarem is necessary (because of severe neutropenia or another medical condition, for example) , monitor carefully for the recurrence of psychotic symptoms and adverse reactions related to cholinergic rebound, such as profuse sweating, headache, nausea, vomiting and diarrhea.
6 ADVERSE REACTIONS
The following adverse reactions are discussed in more detail in other sections of the labeling:
Most common adverse reactions (≥5%) were: CNS reactions (sedation, dizziness/vertigo, headache, and tremor); cardiovascular reactions (tachycardia, hypotension, and syncope); autonomic nervous system reactions (hypersalivation, sweating, dry mouth, and visual disturbances); gastrointestinal reactions (constipation and nausea); and fever (6.1).
To report SUSPECTED ADVERSE REACTIONS, contact Jazz Pharmaceuticals, at 1-800-520-5568 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
The most commonly reported adverse reactions (>5%) across Clozarem clinical trials were: CNS reactions, including sedation, dizziness/vertigo, headache, and tremor; cardiovascular reactions, including tachycardia, hypotension, and syncope; autonomic nervous system reactions, including hypersalivation, sweating, dry mouth, and visual disturbances; gastrointestinal reactions, including constipation and nausea; and fever. Table 9 summarizes the most commonly reported adverse reactions (>5%) in clozapine-treated patients (compared to chlorpromazine-treated patients) in the pivotal, 6-week, controlled trial in treatment-resistant schizophrenia.
Table 9: Common Adverse Reactions (≥5%) in the 6-Week, Randomized, Chlorpromazine-controlled Trial in Treatment-Resistant Schizophrenia
Table 10 summarizes the adverse reactions reported in clozapine-treated patients at a frequency of 2% or greater across all Clozarem studies (excluding the 2-year InterSePT Study). These rates are not adjusted for duration of exposure.
Table 10: Adverse Reactions (≥2%) Reported in Clozapine-treated Patients (N=842) across all Clozarem Studies (excluding the 2-year InterSePT Study)
Table 11 summarizes the most commonly reported adverse reactions (>10% of the Clozarem or olanzapine group) in the InterSePT Study. This was an adequate and well-controlled, two-year study evaluating the efficacy of Clozarem relative to olanzapine in reducing the risk of suicidal behavior in patients with schizophrenia or schizoaffective disorder. The rates are not adjusted for duration of exposure.
Table 11: Incidence of Adverse Reactions in Patients Treated with Clozarem or Olanzapine in the InterSePT Study (≥10% in the Clozarem or olanzapine group)
Class effect: Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.
6.2 Postmarketing Experience
The following adverse reactions have been identified during post-approval use of Clozarem. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Central Nervous System
Delirium, EEG abnormal, myoclonus, paresthesia, possible cataplexy, status epilepticus, obsessive compulsive symptoms, and post-discontinuation cholinergic rebound adverse reactions.
Atrial or ventricular fibrillation, ventricular tachycardia, QT interval prolongation, Torsades de Pointes, myocardial infarction, cardiac arrest, and periorbital edema.
Acute pancreatitis, dysphagia, salivary gland swelling.
Cholestasis, hepatitis, jaundice, hepatotoxicity, hepatic steatosis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, liver injury (hepatic, cholestatic, and mixed), and liver failure.
Immune System Disorders
Angioedema, leukocytoclastic vasculitis.
Acute interstitial nephritis, nocturnal enuresis, priapism, and renal failure.
Skin and Subcutaneous Tissue Disorders
Hypersensitivity reactions: photosensitivity, vasculitis, erythema multiforme, skin pigmentation disorder, and Stevens-Johnson Syndrome.
Musculoskeletal System and Connective Tissue Disorders
Myasthenic syndrome, rhabdomyolysis, and systemic lupus erythematosus.
Aspiration, pleural effusion, pneumonia, lower respiratory tract infection.
Hemic and Lymphatic System
Mild, moderate, or severe leukopenia, agranulocytosis, granulocytopenia, WBC decreased, deep vein thrombosis, elevated hemoglobin/hematocrit, erythrocyte sedimentation rate (ESR) increased, sepsis, thrombocytosis, and thrombocytopenia.
Creatine phosphokinase elevation, hyperuricemia, hyponatremia, and weight loss.
7 DRUG INTERACTIONS
7.1 Potential for Other Drugs to Affect Clozarem
Clozarem is a substrate for many cytochrome P450 isozymes, in particular CYP1A2, CYP3A4, and CYP2D6. Use caution when administering Clozarem concomitantly with drugs that are inducers or inhibitors of these enzymes.
Concomitant use of Clozarem and CYP1A2 inhibitors can increase plasma levels of Clozarem, potentially resulting in adverse reactions. Reduce the Clozarem dose to one third of the original dose when Clozarem is coadministered with strong CYP1A2 inhibitors (e.g., fluvoxamine, ciprofloxacin, or enoxacin). The Clozarem dose should be increased to the original dose when coadministration of strong CYP1A2 inhibitors is discontinued .
Moderate or weak CYP1A2 inhibitors include oral contraceptives and caffeine. Monitor patients closely when Clozarem is coadministered with these inhibitors. Consider reducing the Clozarem dosage if necessary .
CYP2D6 and CYP3A4 Inhibitors
Concomitant treatment with Clozarem and CYP2D6 or CYP3A4 inhibitors (e.g., cimetidine, escitalopram, erythromycin, paroxetine, bupropion, fluoxetine, quinidine, duloxetine, terbinafine, or sertraline) can increase Clozarem levels and lead to adverse reactions . Use caution and monitor patients closely when using such inhibitors. Consider reducing the Clozarem dose .
CYP1A2 and CYP3A4 Inducers
Concomitant treatment with drugs that induce CYP1A2 or CYP3A4 can decrease the plasma concentration of Clozarem, resulting in decreased effectiveness of Clozarem. Tobacco smoke is a moderate inducer of CYP1A2. Strong CYP3A4 inducers include carbamazepine, phenytoin, St. John’s wort, and rifampin. It may be necessary to increase the Clozarem dose if used concomitantly with inducers of these enzymes. However, concomitant use of Clozarem and strong CYP3A4 inducers is not recommended .
Consider reducing the Clozarem dosage when discontinuing coadministered enzyme inducers, because discontinuation of inducers can result in increased Clozarem plasma levels and an increased risk of adverse reactions .
Drugs that Cause QT Interval Prolongation
Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of Clozarem. Drugs that cause QT prolongation include: specific antipsychotics (e.g., ziprasidone, iloperidone, chlorpromazine, thioridazine, mesoridazine, droperidol, and pimozide), specific antibiotics (e.g., erythromycin, gatifloxacin, moxifloxacin, sparfloxacin), Class 1A antiarrhythmics (e.g., quinidine, procainamide) or Class III antiarrhythmics (e.g., amiodarone, sotalol), and others (e.g., pentamidine, levomethadyl acetate, methadone, halofantrine, mefloquine, dolasetron mesylate, probucol or tacrolimus) [see Warnings and Precautions (5.9) ].
7.2 Potential for Clozarem to Affect Other Drugs
Concomitant use of Clozarem with other drugs metabolized by CYP2D6 can increase levels of these CYP2D6 substrates. Use caution when coadministering Clozarem with other drugs that are metabolized by CYP2D6. It may be necessary to use lower doses of such drugs than usually prescribed. Such drugs include specific antidepressants, phenothiazines, carbamazepine, and Type 1C antiarrhythmics (e.g., propafenone, flecainide, and encainide).
8 USE IN SPECIFIC POPULATIONS
Pregnancy Category B
There are no adequate or well-controlled studies of Clozarem in pregnant women.
Reproduction studies have been performed in rats and rabbits at doses up to 0.4 and 0.9 times, respectively, the maximum recommended human dose (MRHD) of 900 mg/day on a mg/m2 body surface area basis. The studies revealed no evidence of impaired fertility or harm to the fetus due to Clozarem. Because animal reproduction studies are not always predictive of human response, Clozarem should be used during pregnancy only if clearly needed.
Consider the risk of exacerbation of psychosis when discontinuing or changing treatment with antipsychotic medications during pregnancy and postpartum. Consider early screening for gestational diabetes for patients treated with antipsychotic medications [see Warnings and Precautions (5.10) ]. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. Monitor neonates for symptoms of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding difficulties. The severity of complications can vary from self-limited symptoms to some neonates requiring intensive care unit support and prolonged hospitalization.
In embryofetal developmental studies, Clozarem had no effects on maternal parameters, litter sizes, or fetal parameters when administered orally to pregnant rats and rabbits during the period of organogenesis at doses up to 0.4 and 0.9 times, respectively, the MRHD of 900 mg/day on a mg/m2 body surface area basis.
In peri/postnatal developmental studies, pregnant female rats were administered Clozarem over the last third of pregnancy and until day 21 postpartum. Observations were made on fetuses at birth and during the postnatal period; the offspring were allowed to reach sexual maturity and mated. Clozarem caused a decrease in maternal body weight but had no effects on litter size or body weights of either F1 or F2 generations at doses up to 0.4 times the MRHD of 900 mg/day on a mg/m2 body surface area basis.
8.3 Nursing Mothers
Clozarem is present in human milk. Because of the potential for serious adverse reactions in nursing infants from Clozarem, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
8.4 Pediatric Use
Safety and effectiveness in pediatric patients have not been established.
8.5 Geriatric Use
There have not been sufficient numbers of geriatric patients in clinical studies utilizing Clozarem to determine whether those over 65 years of age differ from younger subjects in their response to Clozarem.
Orthostatic hypotension and tachycardia can occur with Clozarem treatment . Elderly patients, particularly those with compromised cardiovascular functioning, may be more susceptible to these effects.
Elderly patients may be particularly susceptible to the anticholinergic effects of Clozarem, such as urinary retention and constipation [see Warnings and Precautions (5.15) ].
Carefully select Clozarem doses in elderly patients, taking into consideration their greater frequency of decreased hepatic, renal, or cardiac function, as well as other concomitant disease and other drug therapy. Clinical experience suggests that the prevalence of tardive dyskinesia appears to be highest among the elderly; especially elderly women [see Warnings and Precautions (5.17) ].
8.6 Patients with Renal or Hepatic Impairment
Dose reduction may be necessary in patients with significant impairment of renal or hepatic function. Clozarem concentrations may be increased in these patients, because Clozarem is almost completely metabolized and then excreted .
8.7 CYP2D6 Poor Metabolizers
Dose reduction may be necessary in patients who are CYP2D6 poor metabolizers. Clozarem concentrations may be increased in these patients, because Clozarem is almost completely metabolized and then excreted .
8.8 Hospice Patients
For hospice patients (i.e., terminally ill patients with an estimated life expectancy of 6 months or less), the prescriber may reduce the ANC monitoring frequency to once every 6 months, after a discussion with the patient and his/her caregiver. Individual treatment decisions should weigh the importance of monitoring ANC in the context of the need to control psychiatric symptoms and the patient's terminal illness.
10.1 Overdosage Experience
The most commonly reported signs and symptoms associated with Clozarem overdose are: sedation, delirium, coma, tachycardia, hypotension, respiratory depression or failure, and hypersalivation. There are reports of aspiration pneumonia, cardiac arrhythmias, and seizure. Fatal overdoses have been reported with Clozarem, generally at doses above 2500 mg. There have also been reports of patients recovering from overdoses well in excess of 4 g.
10.2 Management of Overdosage
For the most up-to-date information on the management of Clozarem overdosage, contact a certified Regional Poison Control Center (1-800-222-1222). Telephone numbers of certified Regional Poison Control Centers are listed in the Physicians’ Desk Reference® , a registered trademark of PDR Network. Establish and maintain an airway; ensure adequate oxygenation and ventilation. Monitor cardiac status and vital signs. Use general symptomatic and supportive measures. There are no specific antidotes for Clozarem.
In managing overdosage, consider the possibility of multiple-drug involvement.
Clozarem, an atypical antipsychotic drug, is a tricyclic dibenzodiazepine derivative, 8-chloro-11-(4-methyl-1-piperazinyl)-5H-dibenzo[b,e][1,4]diazepine.
The structural formula is:
Clozarem is available as a free-flowing yellow suspension. Each mL contains 50 mg of Clozarem.
The active component of Clozarem is Clozarem. The remaining components are glycerin, sorbitol (non-crystallizing), sodium dihydrogen phosphate dihydrate, xanthan gum, sodium methylparaben, sodium propylparaben, povidone, water, and sodium hydroxide to adjust to a pH range of 6.5 – 7.0.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
The mechanism of action of Clozarem is unknown. However, it has been proposed that the therapeutic efficacy of Clozarem in schizophrenia is mediated through antagonism of the dopamine type 2 and the serotonin type 2A (5-HT2A) receptors. Clozarem also acts as an antagonist at adrenergic, cholinergic, histaminergic and other dopaminergic and serotonergic receptors.
Clozarem demonstrated binding affinity to the following receptors: histamine H1 (Ki 1.1 nM), adrenergic α1A (Ki 1.6 nM), serotonin 5-HT6 (Ki 4 nM), serotonin 5-HT2A (Ki 5.4 nM), muscarinic M1 (Ki 6.2 nM), serotonin 5-HT7 (Ki 6.3 nM), serotonin 5-HT2C (Ki 9.4 nM), dopamine D4 (Ki 24 nM), adrenergic α2A (Ki 90 nM), serotonin 5-HT3 (Ki 95 nM), serotonin 5-HT1A (Ki 120 nM), dopamine D2 (Ki 160 nM), dopamine D1 (Ki 270 nM), dopamine D5 (Ki 454 nM), and dopamine D3 (Ki 555 nM).
Clozarem causes little or no prolactin elevation.
Clinical electroencephalogram (EEG) studies demonstrated that Clozarem increases delta and theta activity and slows dominant alpha frequencies. Enhanced synchronization occurs. Sharp wave activity and spike and wave complexes may also develop. Patients have reported an intensification of dream activity during Clozarem therapy. REM sleep was found to be increased to 85% of the total sleep time. In these patients, the onset of REM sleep occurred almost immediately after falling asleep.
In man, Clozarem tablets (25 mg and 100 mg) are equally bioavailable relative to a Clozarem solution. Clozarem Oral Suspension is bioequivalent to Clozarem marketed tablets.
Following oral administration of 100 mg to 800 mg Clozarem, once daily, the average steady-state peak plasma concentration was 275 ng/mL (range: 105 - 723 ng/mL), occurring at the average of 2.2 hours (range: 1 - 3.5 hours) after dosing. The average minimum concentration at steady-state was 75 ng/mL (range: 11 - 198 ng/mL).
When Clozarem was administered after a high fat meal there was no effect on the AUCss or Cmin, ss, however Cmax was reduced about 20%, and there was a slight delay in Tmax of 0.5 hour from a median Tmax of 2.0 hours under fasted conditions to 2.5 hours under fed conditions. The decrease in Cmax is not considered clinically relevant. Therefore Clozarem may be taken without regard to meals.
Clozarem is approximately 97% bound to serum proteins. The interaction between Clozarem and other highly protein-bound drugs has not been fully evaluated but may be important .
Metabolism and Excretion
Clozarem is almost completely metabolized prior to excretion, and only trace amounts of unchanged drug are detected in the urine and feces. Clozarem is a substrate for many cytochrome P450 isozymes, in particular CYP1A2, CYP2D6, and CYP3A4. Approximately 50% of the administered dose is excreted in the urine and 30% in the feces. The demethylated, hydroxylated, and N-oxide derivatives are components in both urine and feces. Pharmacological testing has shown the desmethyl metabolite (norclozapine) to have only limited activity, while the hydroxylated and N-oxide derivatives were inactive. The mean elimination half-life of Clozarem after a single 75 mg dose was 8 hours (range: 4-12 hours), compared to a mean elimination half-life of 12 hours (range: 4-66 hours), after achieving steady-state with 100 mg twice daily dosing.
A comparison of single-dose and multiple-dose administration of Clozarem demonstrated that the elimination half-life increased significantly after multiple dosing relative to that after single-dose administration, suggesting the possibility of concentration-dependent pharmacokinetics. However, at steady-state, approximately dose-proportional changes with respect to AUC (area under the curve), peak, and minimum Clozarem plasma concentrations were observed after administration of 37.5, 75, and 150 mg twice daily.
Drug-Drug Interaction Studies
A pharmacokinetic study was conducted in 16 schizophrenic patients who received Clozarem under steady-state conditions. After coadministration of fluvoxamine for 14 days, mean trough concentrations of Clozarem and its metabolites, N-desmethylclozapine and Clozarem N-oxide, were elevated about three-fold compared to baseline steady-state concentrations.
Paroxetine, Fluoxetine, and Sertraline
In a study of schizophrenic patients (n=14) who received Clozarem under steady-state conditions, coadministration of paroxetine produced only minor changes in the levels of Clozarem and its metabolites. However, other published reports describe modest elevations (less than two-fold) of Clozarem and metabolite concentrations when Clozarem was taken with paroxetine, fluoxetine, and sertraline.
Specific Population Studies
Renal or Hepatic Impairment
No specific pharmacokinetic studies were conducted to investigate the effects of renal or hepatic impairment on the pharmacokinetics of Clozarem. Higher Clozarem plasma concentrations are likely in patients with significant renal or hepatic impairment when given usual doses.
CYP2D6 Poor Metabolizers
A subset (3%–10%) of the population has reduced activity of CYP2D6 (CYP2D6 poor metabolizers). These individuals may develop higher than expected plasma concentrations of Clozarem when given usual doses.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No carcinogenic potential was demonstrated in long-term studies in mice and rats at doses up to 0.3 times and 0.4 times, respectively, the maximum recommended human dose (MRHD) of 900 mg/day on a mg/m2 body surface area basis.
Clozarem was not genotoxic when tested in the following gene mutation and chromosomal aberration tests: the bacterial Ames test, the in vitro mammalian V79 in Chinese hamster cells, the in vitro unscheduled DNA synthesis in rat hepatocytes, or the in vivo micronucleus assay in mice.
Impairment of Fertility
Clozarem had no effect on any parameters of fertility, pregnancy, fetal weight, or postnatal development when administered orally to male rats 70 days before mating and to female rats for 14 days before mating at doses up to 0.4 times the MRHD of 900 mg/day on a mg/m2 body surface area basis.
14 CLINICAL STUDIES
14.1 Treatment-Resistant Schizophrenia
The efficacy of Clozarem in treatment-resistant schizophrenia was established in a multicenter, randomized, double-blind, active-controlled study in patients with a DSM-III diagnosis of schizophrenia who had inadequate responses to at least 3 different antipsychotics (from at least 2 different chemical classes) during the preceding 5 years. The antipsychotic trials must have been judged adequate; the antipsychotic dosages must have been equivalent to or greater than 1000 mg per day of chlorpromazine for a period of at least 6 weeks, each without significant reduction of symptoms. There must have been no period of good functioning within the preceding 5 years. Patients must have had a baseline score of at least 45 on the investigator-rated Brief Psychiatric Rating Scale (BPRS). On the 18-item BPRS, 1 indicates the absence of symptoms, and 7 indicates severe symptoms; the maximum potential total BPRS score is 126. At baseline, the mean BPRS score was 61. In addition, patients must have had a score of at least 4 on at least two of the following four individual BPRS items: conceptual disorganization, suspiciousness, hallucinatory behavior, and unusual thought content. Patients must have had a Clinical Global Impressions – Severity Scale score of at least 4 (moderately ill).
In the prospective, lead-in phase of the trial, all patients (N=305) initially received single-blind treatment with haloperidol (the mean dose was 61 mg per day) for 6 weeks. More than 80% of patients completed the 6-week trial. Patients with an inadequate response to haloperidol (n=268) were randomized to double-blind treatment with Clozarem (N=126) or chlorpromazine (N=142). The maximum daily Clozarem dose was 900 mg; the mean daily dose was >600 mg). The maximum daily chlorpromazine dose was 1800 mg; the mean daily dose was >1200 mg.
The primary endpoint was treatment response, predefined as a decrease in BPRS score of at least 20% and either (1) a CGI-S score of <3 (mildly ill), or (2) a BPRS score of <35, at the end of 6 weeks of treatment. Approximately 88% of patients from the Clozarem and chlorpromazine groups completed the 6-week trial. At the end of six weeks, 30% of the Clozarem group responded to treatment, and 4% of the chlorpromazine group responded to treatment. The difference was statistically significant (p<0.001). The mean change in total BPRS score was -16 and -5 in the Clozarem and chlorpromazine group, respectively; the mean change in the 4 key BPRS item scores was -5 and -2 in the Clozarem and chlorpromazine group, respectively; and the mean change in CGI-S score was -1.2 and -0.4, in the Clozarem and chlorpromazine group, respectively. These changes in the Clozarem group were statistically significantly greater than in the chlorpromazine group (p<0.001 in each analysis).
14.2 Recurrent Suicidal Behavior in Schizophrenia or Schizoaffective Disorder
The effectiveness of Clozarem in reducing the risk of recurrent suicidal behavior was assessed in the International Suicide Prevention Trial (InterSePT, a trademark of Novartis Pharmaceuticals Corporation). This was a prospective, randomized, open-label, active-controlled, multicenter, international, parallel-group comparison of Clozarem (Clozaril®) versus olanzapine (Zyprexa®, a registered trademark of Eli Lilly and Company) in 956 patients with schizophrenia or schizoaffective disorder (DSM-IV) who were judged to be at risk for recurrent suicidal behavior. Only about one-fourth of these patients (27%) were considered resistant to standard antipsychotic drug treatment. To enter the trial, patients must have met one of the following criteria:
Dosing regimens for each treatment group were determined by individual investigators and were individualized by patient. Dosing was flexible, with a dose range of 200–900 mg/day for Clozarem and 5–20 mg/day for olanzapine. For the 956 patients who received Clozarem or olanzapine in this study, there was extensive use of concomitant psychotropics: 84% with antipsychotics, 65% with anxiolytics, 53% with antidepressants, and 28% with mood stabilizers. There was significantly greater use of concomitant psychotropic medications among the patients in the olanzapine group.
The primary efficacy measure was time to (1) a significant suicide attempt, including a completed suicide; (2) hospitalization due to imminent suicide risk, including increased level of surveillance for suicidality for patients already hospitalized; or (3) worsening of suicidality severity as demonstrated by “much worsening” or “very much worsening” from baseline in the Clinical Global Impression of Severity of Suicidality as assessed by the Blinded Psychiatrist (CGI-SS-BP) scale. A determination of whether or not a reported event met criterion 1 or 2 above was made by the Suicide Monitoring Board (SMB), a group of experts blinded to patient data.
A total of 980 patients were randomized to the study and 956 received study medication. Sixty-two percent of the patients were diagnosed with schizophrenia, and the remainder (38%) were diagnosed with schizoaffective disorder. Only about one-fourth of the total patient population (27%) was identified as “treatment-resistant” at baseline. There were more males than females in the study (61% of all patients were male). The mean age of patients entering the study was 37 years of age (range: 18–69). Most patients were Caucasian (71%), 15% were Black, 1% were Asian, and 13% were classified as being of “other” races.
Patients treated with Clozarem had a statistically significant longer delay in the time to recurrent suicidal behavior in comparison with olanzapine. This result should be interpreted only as evidence of the effectiveness of Clozarem in delaying time to recurrent suicidal behavior and not a demonstration of the superior efficacy of Clozarem over olanzapine.
The probability of experiencing (1) a significant suicide attempt, including a completed suicide, or (2) hospitalization because of imminent suicide risk, including increased level of surveillance for suicidality for patients already hospitalized, was lower for Clozarem patients than for olanzapine patients at Week 104: Clozarem 24% versus olanzapine 32%; 95% CI of the difference: 2%, 14% (Figure 1).
Figure 1. Cumulative Probability of a Significant Suicide Attempt or Hospitalization to Prevent Suicide in Patients with Schizophrenia or Schizoaffective Disorder at High Risk of Suicidality
16 HOW SUPPLIED/STORAGE AND HANDLING
16.1 How Supplied
Free-flowing, yellow suspension in amber bottle containing 100 mL. Each box contains 1 x 1 mL oral syringe, 1 x 9 mL oral syringe and 1 bottle adaptor.
NDC No. 18860-121-01
16.2 Storage and Handling
Store Clozarem at or below 25°C (77°F). Do not refrigerate or freeze. Protect from light. Shake well for 10 seconds before use.
The suspension is stable for 100 days after initial bottle opening.
Keep out of reach of children.
17 PATIENT COUNSELING INFORMATION
Discuss the following issues with patients and caregivers:
Jazz Pharmaceuticals, Inc.
Palo Alto, CA 94304
U.S. Patent No. 8057811
Clozarem® is a trademark of Jazz Pharmaceuticals plc or its subsidiaries.
Revised: February 2017
Clozarem® (VER sa kloz)
Read this Patient Information before you start taking Clozarem and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment.
What is the most important information I should know about Clozarem?
Clozarem can cause serious side effects, including:
1. Severe neutropenia, a blood disorder that can lead to serious infections and death. Severe neutropenia means that you do not have enough of certain white blood cells to fight infection. Tell your healthcare provider right away if you have any of the following symptoms or signs of neutropenia or infection:
If you have symptoms of severe neutropenia or infection you will need to have a blood test right away to check if Clozarem is causing your symptoms. You must have frequent blood tests while taking Clozarem so your healthcare provider can make sure you are not getting severe neutropenia or infection.
Clozarem is available only through a restricted program called the Clozarem REMS Program. This program makes sure that you will receive each refill of Clozarem only if you have a blood test and your blood test result is acceptable to your healthcare provider.
During your first 6 months of Clozarem treatment, you will have weekly blood tests. If you have not taken Clozarem before, you will need weekly blood tests when you first start Clozarem. If you have acceptable blood test results during your first 6 months of Clozarem treatment, you can have a blood test every other week for the next 6 months. After a year of acceptable blood test results, you can have blood tests every 4 weeks while you are taking Clozarem.
2. Decreased blood pressure (orthostatic hypotension), slow heart rate (bradycardia), or fainting (syncope) that can lead to death. Lightheadedness or fainting caused by a sudden change in your heart rate and blood pressure when you rise too quickly from a sitting or lying position can happen while you take Clozarem and can be life threatening. These problems may happen more often when you are first starting treatment with Clozarem or when your dose is increased. Tell your healthcare provider right away if you feel faint, lose consciousness, or have symptoms of slow heart rate or an irregular heart rhythm.
3. Seizures. Seizures can occur during Clozarem treatment. Be especially careful while driving or during any other dangerous activity while taking Clozarem.
4. Myocarditis (heart muscle inflammation) and cardiomyopathy (heart muscle weakness) that may lead to death. Symptoms of myocarditis and cardiomyopathy include:
5. Higher risk of death in elderly people with memory loss (dementia) or psychosis. Clozarem can increase the risk of death in elderly people who have dementia. Clozarem is not for treating psychosis in elderly people with dementia.
What is Clozarem?
Clozarem is a prescription antipsychotic medicine used to treat people with certain types of schizophrenia, including people who:
It is not known if Clozarem is safe and effective in children.
Who should not take Clozarem?
Do not take Clozarem if you:
What should I tell my healthcare provider before taking Clozarem?
Before you take Clozarem, tell your healthcare provider about all of your medical conditions, including if you:
Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.
Clozarem and other medicines may affect each other causing side effects.
Especially tell your healthcare provider if you take:
Ask your healthcare provider for a list of these medicines if you are not sure.
Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine.
How should I take Clozarem?
The symptoms of Clozarem overdose can include:
If you miss a dose of Clozarem for more than 2 days, check with your healthcare provider before starting to take it again to make sure you take the correct dose.
What should I avoid while taking Clozarem?
What are the possible side effects of Clozarem?
Clozarem may cause serious side effects, including:
The most common side effects of Clozarem include:
Tell your healthcare provider if you have any side effect that bothers you or that does not go away.
These are not all the possible side effects of Clozarem. For more information, ask your healthcare provider or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
How should I store Clozarem?
Keep Clozarem and all medicines out of the reach of children.
General information about the safe and effective use of Clozarem
Medicines are sometimes prescribed for purposes other than those listed in a Patient Information Leaflet. Do not use Clozarem for a condition for which it was not prescribed. Do not give Clozarem to other people, even if they have the same symptoms that you have. It may harm them.
This Patient Information Leaflet summarizes the most important information about Clozarem. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for more information about Clozarem that is written for healthcare professionals.
For more information, go to www. VERSACLOZ.com or call 1-800-520-5568.
What are the ingredients in Clozarem?
Active ingredient: Clozarem
Inactive ingredients: glycerin, sorbitol (non-crystallizing), sodium dihydrogen phosphate dihydrate, xanthan gum, sodium methylparaben, sodium propylparaben, povidone, water, and sodium hydroxide
Instructions for Use
Clozarem® (VER sa kloz)
Supplies you will need to take your Clozarem dose:
Disposal of your oral syringe, empty Clozarem bottle and bottle neck adaptor:
Place the cap back on the empty Clozarem bottle before you throw it away. The oral syringe, empty bottle and bottle neck adaptor should be placed in your household trash when you finish your bottle of Clozarem. The oral syringe should not be shared with other people or used for medicines other than Clozarem.
Jazz Pharmaceuticals, Inc.
Palo Alto, CA 94304 USA
This Patient Information and the Instructions for Use have been approved by the U.S. Food and Drug Administration.
Revised: February 2017
symptoms of myocarditis and cardiomyopathy symptoms side effects Figure-03 Patient Use Figure A Step 1 Figure B Step 2 Figure C Step 3 Figure D-01 Figure D-02 Step 4 Figure E Step 5 Figure F Step 6 Figure G Step 7 Figure H Step 8 Figure I Step 9 Figure J Step 10 Figure K Step 11 Figure L Step 12 Figure M Step 13 Figure N Step 14
(clozapine) Oral Suspension
Clozarem pharmaceutical active ingredients containing related brand and generic drugs:
Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.
Clozarem available forms, composition, doses:
Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.
Clozarem destination | category:
Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.
Clozarem Anatomical Therapeutic Chemical codes:
A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.
Clozarem pharmaceutical companies:
Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.
Frequently asked QuestionsCan i drive or operate heavy machine after consuming Clozarem?
Depending on the reaction of the Clozarem after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Clozarem not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Clozarem addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
Reviewsdrugs.com conducted a study on Clozarem, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Clozarem consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.
Visitor reported usefulNo survey data has been collected yet
Visitor reported side effectsNo survey data has been collected yet
One visitor reported price estimatesWhat is your opinion about drug cost? Did you feel the cost is apt, or did you feel it is expensive?
The report given by the sdrugs.com website users shows the following figures about several people who felt the medicine Clozarem is expensive, and the medicine is not expensive. The results are mixed. The perception of the cost of the medicine to be expensive or not depends on the brand name of the medicine, country, and place where it is sold, and the affordability of the patient. You can choose a generic drug in the place of the branded drug to save the cost. The efficiency of the medicine will not vary if it is generic or a branded one.
Visitor reported frequency of useNo survey data has been collected yet
One visitor reported dosesWhat is the dose of Clozarem drug you are taking?
According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 101-200mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
Visitor reported time for resultsNo survey data has been collected yet
Visitor reported administrationNo survey data has been collected yet
Two visitors reported age
The information was verified by Dr. Arunabha Ray, MD Pharmacology