Brianne M. Newman, MD Associate Professor of Psychiatry Department of Psychiatry Saint Louis University School of Medicine St. Louis, Missouri
William J. Newman, MD Associate Professor of Psychiatry Department of Psychiatry Saint Louis University School of Medicine St. Louis, Missouri Member of the Editorial Board of Current Psychiatry
A 2015 review of psychotropic medications and pregnancy noted that approximately 60% of women with schizophrenia became pregnant, with an increased incidence of unplanned pregnancy. A high risk of psychotic relapse (65%) during pregnancy and in the postpartum period may lead to insufficient prenatal care, drug use, and obstetric complications.45 Some data suggest low fetal birth weight and an increased rate of therapeutic abortions in women with schizophrenia.42,46
When treating a pregnant patient, weigh the benefits of clozapine against the risks of adverse events, and clearly document the analysis. Clozapine treatment is not recommended during breast-feeding because of the risk of side effects for newborns.8
We highly recommend keeping updated on the literature regarding pregnancy and lactation information with antipsychotics, including clozapine, because prescribing information will likely be updated in the near future to comply with recent FDA labeling changes.
Final installment: Using clozapine off-labelClozapine is FDA-approved for refractory schizophrenia and for reducing the risk of recurrent suicidal behavior in schizophrenia or schizoaffective disorder. In Part 3 of this series, we review off-label uses—such as managing bipolar disorder, borderline personality disorder, and aggressive behavior—that have varying degrees of scientific support.
Bottom LineClozapine is highly efficacious but requires greater clinician monitoring than most other psychotropics. Early identification and management of side effects can help patients continue clozapine, which is associated with reduced risk of mortality from natural and unnatural causes.
Related Resources
ACOG Committee on Practice Bulletins–Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. 2008;111(4):1001-1020.
Smith TL, Mican LM. What to do when your patient who takes clozapine enters a smoke-free facility. Current Psychiatry. 2014;13(5):47-48,57.
U.S. Food and Drug Administration. Pregnancy and Lactation Labeling (Drugs) Final Rule. https://s3.amazonaws.com/ public-inspection.federalregister.gov/2014-28241.pdf.
Disclosures The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
