Case series and case reports are also evidence-based and this type of evidence is critical where a therapeutic gap exists, such as in this patient population of severe personality disorder. The American find more Psychiatric Association practice guideline for borderline personality disorder mentions clozapine as a treatment that could be used when other treatments fail [Oldham et al. 2001]. We believe that clozapine offers considerable
benefit to severely ill self-injurious patients with BPD and should be considered Inhibitors,research,lifescience,medical for appropriate candidates. In our experience, approximately 75% of such patients treated with clozapine respond favorably. Footnotes Funding: The authors report no financial support for this
case series. Conflict of interest statement: T.Z. reports no conflict of interest. J.M. has received grant support from Merck, Roche/Genentech and PsychoGenics, and speakers’ fees from Eli Lilly and Sunovion. Contributor Information Theodore Zarzar, Central Regional Hospital, 300 Veazey Road, Inhibitors,research,lifescience,medical Butner, NC 27509, USA. Joseph McEvoy, Central Regional Hospital, Butner, NC, USA.
The effectiveness of clozapine as therapy for treatment-resistant schizophrenia is well established [Kane et Inhibitors,research,lifescience,medical al. 1988; McEvoy et al. 2006; Lewis et al. 2006]. There is also extensive literature covering the effectiveness of clozapine in reduction of aggression [Glazer et al. 1998; Hector, 1998; Rabinowitz et al. 1996; Spivak et al. 1997; Inhibitors,research,lifescience,medical Volovka, 1999; Volovka et al. 2004; Buckley et al. 1995], self-harm and suicide [Duggan et al. 2003] and adverse incidents [Beer et al. 2006] in various psychiatric settings. However, in spite of superior efficacy to other antipsychotic medications, the use of clozapine Inhibitors,research,lifescience,medical had been reserved for treatment-resistant disease [National Institute for Health and Clinical Excellence, 2009] because of the risk of serious adverse reactions [Kilian et al. 1999]. The occurrence of agranulocytosis is a substantial hazard in the administration of clozapine, but this hazard can be reduced, or managed, by monitoring the white cell count [Alvir et al. 1993]. Of the patients
taking clozapine about 3% develop neutropenia (neutrophil count < 1.5 × 109/liter) and 1% develop agranulocytosis (neutrophil count < 0.3 × 109/liter) [Alvir et al. 1993; Atkin et al. 1996]. Among those who have been rechallenged there is evidence that neutropenia unless occurs more quickly on rechallenge than the first episode of neutropenia, lasts longer and is more severe [Dunk, 2006]. Unsurprisingly the authors have not been able to find any case in the literature in whom a third rechallenge of clozapine following neutropenia was attempted. Neutropenia is a frequent problem in patients with haematological malignancies; following cancer chemotherapy; with idiosyncratic drug reactions; and in some viral infections and autoimmune disorders.