A patient with treatment-resistant schizophrenia is started on clozapine. After 6 weeks, his ANC drops to 750 cells/µL. According to REMS guidelines, what is the appropriate management?
- A Continue clozapine with daily ANC monitoring
- B Immediately discontinue clozapine permanently
- C Interrupt clozapine and consider G-CSF; re-challenge depends on nadir ✓
- D Reduce clozapine dose by 50% and recheck ANC in 3 days
Correct answer: C. Interrupt clozapine and consider G-CSF; re-challenge depends on nadir
Explanation
According to updated Clozapine REMS, an ANC of 500–999 cells/µL is severe neutropenia requiring interruption of clozapine. G-CSF (filgrastim) can be used to accelerate recovery. Re-challenge (below 500/µL: generally do not rechallenge; 500–999: rechallenge allowed with caution once ANC recovers to ≥1000). In this patient with ANC 750, clozapine should be interrupted, ANC monitored more frequently, and G-CSF considered. Permanent discontinuation is required only if ANC falls below 500 (agranulocytosis) without compelling clinical justification.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.