The Future Direction of Monitoring Medications at Home:

Clozapine is an atypical antipsychotic that is used for clients who present with treatment-resistant schizophrenia (Dixon, 2014). Clozapine is the drug of choice for patients with treatment-resistant schizophrenia, showing a response rate of about 50% despite their unresponsiveness to other antipsychotics (Neilsen et al., 2012). Although treatment with clozapine can lead to considerable savings on bed days, the drug is underutilized for several reasons, perhaps most importantly because of the mandatory hematological monitoring (Neilsen et al., 2012). The drug is subject to strict monitoring requirements because it is associated with serious side effects, such as neutropenia, agranulocytosis, seizures, myocarditis and cardiomyopathy (Dixon, 2014). The monitoring of blood work is indeed strict. In Ontario, to be started on clozapine a client must first have baseline blood work completed to provide a White Blood Cell (WBC) count and an Absolute Neutrophil Count (ANC) as well as an ECG to determine if there are any cardiac implications for the client. Once approved, the client must complete the WBC and ANC blood work every seven days for the first six months of treatment. If the lab values are within normal ranges for that time period the client can then graduate to a WBC and ANC being tested every two weeks for the next six months. Again, if the values remain within normal ranges then they can again graduate to the next step. After one year of testing within normal ranges, the client can then move to completing the blood work once a month for the remainder of the time that they are being treated by the medication.

This is a major deterrent for the population of clients that is being served by the medication. There are a few assumptions that are being made about the client’s ability to participate in the treatment; one being that they are physically able to go to a lab, that they have transportation to go to a lab, and that they have the proper identification to have lab testing done. Unfortunately, these are not always criteria that clients with treatment resistant schizophrenia can meet and therefore were not able to be treated by this medication. As a nurse, I felt defeated that I was unable to support or advocate for my clients who I felt would benefit from this medication. It was discouraging that we could monitor blood sugar for diabetics through a finger prick but we could not get simple lab values from the same method. I learned that many other clinicians shared my frustration and recently I have learned about point of care testing for clozapine monitoring.

The tool used to monitor WBC and ANC was created by HLS Therapeutics and was designed to streamline blood testing for both patients and healthcare practitioners by enabling patients to have their blood monitoring work done in the client’s home or the clinician’s office (Cision, 2019). The device which is named CSAN Pronto, uses imaging technology and artificial intelligence to quantitatively determine white blood cell and Neutrophil percentages from a finger prick blood test and produces results to the client’s online portal in real time (Cision, 2019). The benefit of offering point of care testing for the use of clozapine monitoring will be the availability of the treatment to clients who otherwise would not be able to meet the demands of the monitoring requirements. Nurses are now able to complete all the monitoring requirements in the client’s home resulting in more streamlined use of direct service time. Nurses are no longer spending time transporting clients to and from labs, waiting at appointments, and waiting for results to be generated. The availability of results in real time will eliminate inconclusive readings and repeat trips to the labs. Nurses will also be able to react to any outstanding findings in a timely manner and provide interventions faster.

This is a change in practice that will have meaningful results to both clinicians and clients alike. I am excited to bring this tool to my clinic in January 2020 when it will be made available to my region. I believe this is an accurate representation of pharmaceutical companies hearing the advocacy of front line workers to meet the needs of the clients. In the future, I believe that there will be more point of care testing available to homecare nurses and more interventions being supplied in client’s homes rather than in an inpatient environment. I am excited to involved in this innovative practice and believe this is only the beginning of the next generation of medical monitoring.

References:

Cision. (2019, October 17). HLS Therapeutics announces Health Canada grants medical device license for White Blood Cell Point-of-Care Device to be marketed as CSAN® PRONTO™ . Retrieved November 25, 2019, from Cision: https://www.newswire.ca/news-releases/hls-therapeutics-announces-health-canada-grants-medical-device-license-for-white-blood-cell-point-of-care-device-to-be-marketed-as-csan-r-pronto-tm--899297239.html

Dixon, M. (2014, June 2). How clozapine can be monitored safely and effectively. Retrieved November 25, 2019, from The Pharmaceutical Journal: https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/how-clozapine-patients-can-be-monitored-safely-and-effectively/11138788.article?firstPass=false

Nielsen, J., Thode. D., Stengar, E., Andersen, K., Sondrup, U., Hansen, TN., Munk, AM., Lykkegaard, S., Gosvig, A., Petrov, I., Le Quach, P. (2012). Hematological clozapine monitoring with a point-of-care device: a randomized cross-over trial. National Centre for Biotechnological Information, 1-3.