Clozapine
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Unconscious and absence of palpable pulse following medication error: case report A male patient [age not stated] developed unconsciousness and absence of palpable pulse following inadvertent administration of wrong dose of clozapine, which was prescribed as an off-label treatment for bipolar disorder. The patient presented to a hospital with confusion and agitation. He had bipolar disorder and had been receiving off-label treatment with clozapine. However, he had not been taking the drug for the past several weeks. On admission, he was restarted on his regular dosage of clozapine, i.e. the target maintenance dose of clozapine for bipolar disorder was 100 to 300 mg/day. Afterwards, he was found unconscious with absence of a palpable pulse [time to reactions onsets not stated]. The man was then successfully resuscitated. It was later determined that, while restarting clozapine in patients who have not been taking it for two days or more, the dose must be administered at 12.5mg once or twice daily, which was necessary to minimize the risk of bradycardia, hypotension or syncope, which are mentioned in the product’s boxed warning. Despite that, the man inadvertently received wrong dose of clozapine (medication error). Gaunt MJ. These 2 Potential Errors May Go Unseen. Pharmacy Times 2020: Aug 2020
0114-9954/20/1831-0001/$14.95 Adis © 2020 Springer Nature Switzerland AG. All rights reserved
803516043
Reactions 21 Nov 2020 No. 1831
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