Trigoboff Eileen, Grace Jeffery, Szymanski Herman, Bhullar Jaspinder, Lee Claudia, Watson Thomas
Drs. Trigoboff, Grace, and Lee are from the Buffalo Psychiatric Center in Buffalo, New York, and the State University of New York at Buffalo; Mr. Watson is from the Buffalo Psychiatric Center in Buffalo, New York; and Dr. Szymanski is from the State University of New York at Buffalo.
Innov Clin Neurosci. 2013 May;10(5-6):20-7.
This case study compares two different clinical outcomes for a patient with a long-standing psychotic disorder prescribed clozapine on two occasions. During the first trial, clozapine was used at a higher dose for this patient (350-450mg/day) and included clinically significant sialorrhea, pneumonia, and pneumonia-like illnesses requiring immediate medical intervention including hospitalization. There were also patient complaints of fatigue, cough, choking, and constipation leading to poor adherence. Clozapine was discontinued when the patient withdrew his consent due to side effects, despite his awareness of its benefits, including reduction of command hallucinations and irritability. The second clozapine trial was associated with lower daily doses and therapeutic serum blood levels. The patient was actively participating in and adhering to the medication plan. A very narrow window of clozapine dose was exceeded for two days and the patient complained of hypersalivation, cough, and lethargy. He was subsequently hospitalized for a two week period to treat aspiration pneumonia. This hospitalization helped establish the ideal daily dose of clozapine for this patient and also brought the relationship between aspiration pneumonia and clozapine to the attention of the psychiatrist and medical specialist. Once the appropriate dosage for this patient was established, his psychotic and affective symptoms were controlled, he was not hampered by adverse side effects, and he started to actively participate in social and recreational activities and plans that culminated in discharge from a state psychiatric facility to a supportive community residence. It is our hope that the lessons we have learned from our shared experience with this patient will be of benefit to other clinicians and patients.
本案例研究比较了一名患有长期精神障碍的患者两次服用氯氮平后的两种不同临床结果。在第一次试验中，该患者服用氯氮平的剂量较高（350 - 450毫克/天），出现了具有临床意义的流涎、肺炎以及需要立即进行医疗干预（包括住院治疗）的类肺炎疾病。患者还抱怨疲劳、咳嗽、呛噎和便秘，导致依从性差。尽管患者意识到氯氮平的益处，包括减少命令性幻听和易怒情绪，但由于副作用，他撤回同意后，氯氮平被停用。第二次氯氮平试验的每日剂量和治疗性血清血药浓度较低。患者积极参与并坚持药物治疗方案。有两天超过了氯氮平剂量的非常窄的范围，患者抱怨唾液分泌过多、咳嗽和嗜睡。随后他因吸入性肺炎住院两周。这次住院有助于确定该患者氯氮平的理想每日剂量，也使精神科医生和医学专家注意到吸入性肺炎与氯氮平之间的关系。一旦确定了该患者的合适剂量，他的精神病性和情感症状得到控制，未受到不良副作用的影响，并且他开始积极参与社交和娱乐活动及计划，最终从州立精神病院出院，住进了提供支持的社区住所。我们希望从与该患者的共同经历中学到的经验教训能对其他临床医生和患者有所帮助。
