Clozapine

Pronunciation

Dosage Form: tablet

WARNING: AGRANULOCYTOSIS; ORTHOSTATIC HYPOTENSION, BRADYCARDIA, AND SYNCOPE; SEIZURE; MYOCARDITIS AND CARDIOMYOPATHY; INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Agranulocytosis

Clozapine treatment has caused agranulocytosis, defined as an absolute neutrophil count (ANC) less than 500/mm3. Agranulocytosis can lead to serious infection and death. Prior to initiating treatment with Clozapine, obtain a baseline white blood cell (WBC) count and ANC. The ANC must be greater than or equal to 2000/mm3 and the WBC must be greater than or equal to 3500/mm3 for a patient to begin treatment with Clozapine. During treatment, patients must have regular monitoring of ANC and WBC. Discontinue Clozapine and do not rechallenge if the ANC is less than 1000/mm3 or the WBC is less than 2000/mm3. Advise patients to immediately report symptoms consistent with agranulocytosis or infection (e.g., fever, weakness, lethargy, or sore throat) [see Dosage and Administration (2.1), Warnings and Precautions (5.1)].

Because of the risk of agranulocytosis, Clozapine is available only through a restricted program called the Teva Clozapine Patient Registry. Under the Teva Clozapine Patient Registry, prescribers, patients, and pharmacies must enroll in the program [see Warnings and Precautions (5.2)].

Orthostatic Hypotension, Bradycardia, Syncope

Orthostatic hypotension, bradycardia, syncope, and cardiac arrest have occurred with Clozapine treatment. The risk is highest during the initial titration period, particularly with rapid dose escalation. These reactions can occur with the first dose, with doses as low as 12.5 mg per day. Initiate treatment at 12.5 mg once or twice daily; titrate slowly; and use divided dosages. Use Clozapine cautiously in patients with cardiovascular or cerebrovascular disease or conditions predisposing to hypotension (e.g., dehydration, use of antihypertensive medications) [see Dosage and Administration (2.2, and 2.5), Warnings and Precautions (5.3)].

Seizures

Seizures have occurred with Clozapine treatment. The risk is dose-related. Initiate treatment at 12.5 mg, titrate gradually, and use divided dosing. Use caution when administering Clozapine to patients with a history of seizures or other predisposing risk factors for seizure (CNS pathology, medications that lower the seizure threshold, alcohol abuse). Caution patients about engaging in any activity where sudden loss of consciousness could cause serious risk to themselves or others [see Dosage and Administration (2.2), Warnings and Precautions (5.4)].

Myocarditis and Cardiomyopathy

Fatal myocarditis and cardiomyopathy have occurred with Clozapine treatment. Discontinue Clozapine and obtain a cardiac evaluation upon suspicion of these reactions. Generally, patients with Clozapine-related myocarditis or cardiomyopathy should not be rechallenged with Clozapine. Consider the possibility of myocarditis or cardiomyopathy if chest pain, tachycardia, palpitations, dyspnea, fever, flu-like symptoms, hypotension, or ECG changes occur [see Warnings and Precautions (5.5)].

Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Clozapine is not approved for use in patients with dementia-related psychosis [see Warnings and Precautions (5.6)].

Indications and Usage for Clozapine

Treatment Resistant Schizophrenia

Clozapine tablets USP are indicated for the treatment of severely ill patients with schizophrenia who fail to respond adequately to standard antipsychotic treatment. Because of the significant risk of agranulocytosis and seizure associated with their use, Clozapine tablets USP should be used only in patients who have failed to respond adequately to standard antipsychotic treatment [see Warnings and Precautions (5.1, 5.4)].

The effectiveness of Clozapine tablets USP in treatment-resistant schizophrenia was demonstrated in a 6 week, randomized, double-blind, active-controlled study comparing Clozapine tablets USP and chlorpromazine in patients who had failed other antipsychotics [see Clinical Studies (14.1)].

Reduction in the Risk of Recurrent Suicidal Behavior in Schizophrenia or Schizoaffective Disorder

Clozapine tablets USP are indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder who are judged to be at chronic risk for re-experiencing suicidal behavior, based on history and recent clinical state. Suicidal behavior refers to actions by a patient that put him/herself at risk for death.

The effectiveness of Clozapine tablets USP in reducing the risk of recurrent suicidal behavior was demonstrated over a 2 year treatment period in the InterSePT™ trial [see Clinical Studies (14.2)].

Clozapine Dosage and Administration

Required Laboratory Testing Prior to Initiation and During Therapy

Prior to initiating treatment with Clozapine tablets, obtain a complete blood count (CBC) with differential. The absolute neutrophil count (ANC) must be greater than or equal to 2000/mm3 and the WBC must be greater than or equal to 3500 mm3 in order to initiate treatment. To continue treatment, the ANC and WBC must be monitored regularly [see Warnings and Precautions (5.1)].

Dosing Information

The starting dose is 12.5 mg once daily or twice daily. The total daily dose can be increased in increments of 25 mg to 50 mg per day, if well-tolerated, to achieve a target dose of 300 mg to 450 mg per day (administered in divided doses) by the end of 2 weeks. Subsequently, the dose can be increased once weekly or twice weekly, in increments of up to 100 mg. The maximum dose is 900 mg per day. To minimize the risk of orthostatic hypotension, bradycardia, and syncope, it is necessary to use this low starting dose, gradual titration schedule, and divided dosages [see Warnings and Precautions (5.3)].

Clozapine tablets can be taken with or without food [see Pharmacokinetics (12.3)].

Maintenance Treatment

Generally, it is recommended that patients responding to Clozapine tablets continue maintenance treatment on their effective dose beyond the acute episode.

Discontinuation of Treatment

In the event of planned termination of Clozapine tablets therapy, reduce the dose gradually over a period of 1 to 2 weeks. If abrupt discontinuation is necessary (because of agranulocytosis or another medical condition, for example), monitor carefully for the recurrence of psychotic symptoms and symptoms related to cholinergic rebound such as profuse sweating, headache, nausea, vomiting, and diarrhea.

Re-Initiation of Treatment

When restarting Clozapine tablets in patients who have discontinued Clozapine tablets (i.e., 2 days or more since the last dose), re-initiate with 12.5 mg once daily or twice daily. This is necessary to minimize the risk of hypotension, bradycardia, and syncope [see Warnings and Precautions (5.3)]. If that dose is well tolerated, the dose may be increased to the previously therapeutic dose more quickly than recommended for initial treatment.

Dosage Adjustments with Concomitant use of CYP1A2, CYP2D6, CYP3A4 Inhibitors or CYP1A2, CYP3A4 Inducers

Dose adjustments may be necessary in patients with concomitant use of: strong CYP1A2 inhibitors (e.g., fluvoxamine, ciprofloxacin, or enoxacin); moderate or weak CYP1A2 inhibitors (e.g., oral contraceptives, or caffeine); CYP2D6 or CYP3A4 inhibitors (e.g., cimetidine, escitalopram, erythromycin, paroxetine, bupropion, fluoxetine, quinidine, duloxetine, terbinafine, or sertraline); CYP3A4 inducers (e.g., phenytoin, carbamazepine, St. John’s wort, and rifampin); or CYP1A2 inducers (e.g., tobacco smoking) (Table 1) [see Drug Interactions (7)].  

Table 1: Dose Adjustment in Patients Taking Concomitant Medications

Comedications

Scenarios

Initiating Clozapine tablets while taking a comedication

Adding a comedication while taking Clozapine tablets

Discontinuing a

comedication while continuing Clozapine tablets

Strong CYP1A2 Inhibitors

Use one-third of the Clozapine tablets dose.

Increase Clozapine tablets dose based on clinical response.

Moderate or Weak CYP1A2 Inhibitors

Monitor for adverse reactions. Consider reducing the Clozapine tablets dose if necessary.

Monitor for lack of effectiveness. Consider increasing Clozapine tablets dose if necessary.

CYP2D6 or CYP3A4 Inhibitors

Strong CYP3A4 Inducers

Concomitant use is not recommended. However, if the inducer is necessary, it

may be necessary to increase the Clozapine tablets dose. Monitor for decreased effectiveness.

Reduce Clozapine tablets dose based on clinical response.

Moderate or weak CYP1A2 or CYP3A4 Inducers

Monitor for decreased effectiveness. Consider increasing the Clozapine tablets dose if necessary.

Monitor for adverse reactions. Consider reducing the Clozapine tablets dose if necessary.

Renal or Hepatic Impairment or CYP2D6 Poor Metabolizers

It may be necessary to reduce the Clozapine tablets dose in patients with significant renal or hepatic impairment, or in CYP2D6 poor metabolizers [see Use in Specific Populations (8.6, 8.7)].

Dosage Forms and Strengths

Clozapine tablets are available as 25 mg, 50 mg, 100 mg, and 200 mg pale-yellow tablets with a score on one side.

Contraindications

History of Clozapine-induced Agranulocytosis or Severe Granulocytopenia

Clozapine tablets are contraindicated in patients with a history of Clozapine-induced agranulocytosis or severe granulocytopenia [see Warnings and Precautions (5.1)].

Hypersensitivity

Clozapine tablets are contraindicated in patients with a history of hypersensitivity to Clozapine (e.g., photosensitivity, vasculitis, erythema multiforme, or Stevens-Johnson syndrome) or any other component of Clozapine tablets [see Adverse Reactions (6.2)].

Warnings and Precautions

Agranulocytosis

Background

Agranulocytosis, defined as an ANC of less than 500/mm3, has been estimated to occur in association with Clozapine use at a cumulative incidence at 1 year of approximately 1.3%, based on the occurrence of 15 US cases out of 1743 patients exposed to Clozapine tablets during their clinical testing prior to domestic marketing. All of these cases occurred at a time when the need for close monitoring of WBC counts was already recognized. A hematologic risk analysis was conducted based upon the available information in the CLOZARIL® National Registry for US patients. Based upon a cut-off date of April 30, 1995, the incidence rates of agranulocytosis based upon a weekly monitoring schedule rose steeply during the first 2 months of therapy, peaking in the third month. Among Clozapine patients who continued the drug beyond the third month, the weekly incidence of agranulocytosis fell a substantial degree. After 6 months, the weekly incidence of agranulocytosis declines still further; however, it never reaches zero. It should be noted that any type of reduction in the frequency of monitoring WBC counts may result in an increased incidence of agranulocytosis.

Risk Factors

Experience from clinical development, as well as from examples in the medical literature, suggests that patients who have developed agranulocytosis during Clozapine therapy are at increased risk of subsequent episodes of agranulocytosis. Analysis of WBC count data from the CLOZARIL® National Registry also suggests that patients who have an initial episode of moderate leukopenia (3000/mm3 > WBC count ≥ 2000/mm3) are at an increased risk of subsequent episodes of agranulocytosis. Except for bone-marrow suppression during initial Clozapine therapy, there are no other established risk factors based on worldwide experience for the development of agranulocytosis in association with Clozapine use. However, a disproportionate number of the US cases of agranulocytosis occurred in patients of Jewish background compared to the overall proportion of such patients exposed during domestic development of Clozapine. Most of the US cases of agranulocytosis occurred within 4 to 10 weeks of exposure, but neither dose nor duration is a reliable predictor of this problem. Agranulocytosis associated with other antipsychotic drugs has been reported to occur with a greater frequency in women, the elderly, and in patients who are cachectic or have serious underlying medical illness; such patients may also be at particular risk with Clozapine, although this has not been definitively demonstrated.

WBC Count and ANC Clinical Monitoring Schedule

Clozapine is available only through a distribution system that ensures monitoring of WBC count and ANC according to the schedule described below prior to delivery of the next supply of medication.

As described in Table 2, patients who are being treated with Clozapine must have a baseline WBC count and ANC before initiation of treatment, and a WBC count and ANC every week for the first 6 months. Thereafter, if acceptable WBC counts and ANCs (WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3) have been maintained during the first 6 months of continuous therapy, WBC counts and ANCs can be monitored every 2 weeks for the next 6 months. Thereafter, if acceptable WBC counts and ANCs (WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3) have been maintained during the second 6 months of continuous therapy, WBC count and ANC can be monitored every 4 weeks.

When treatment with Clozapine is discontinued (regardless of the reason), WBC count and ANC must be monitored weekly for at least 4 weeks from the day of discontinuation or until WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3.

Table 2 provides a summary of the frequency of monitoring that should occur based on various stages of therapy (e.g., initiation of therapy) or results from WBC count and ANC monitoring tests (e.g., moderate leukopenia). The text that follows should be consulted for additional details regarding the treatment of patients under the various conditions (e.g., severe leukopenia).

Advise patients to immediately report the appearance of signs/symptoms consistent with agranulocytosis or infection (e.g., fever, weakness, lethargy, or sore throat) at any time during Clozapine therapy. Such patients should have a WBC count and an ANC performed promptly.

Table 2. Frequency of Monitoring Based on Stage of Therapy or Results from WBC Count and ANC Monitoring Tests

Situation

Hematological Values for Monitoring

Frequency of WBC Count and ANC Monitoring

Initiation of therapy

WBC count ≥ 3500/mm3

Weekly for 6 months

and

ANC ≥ 2000/mm3

Note: Do not initiate in patients with a history of Clozapine-induced agranulocytosis or severe granulocytopenia.

6 to 12 months of therapy

WBC ≥ 3500/mm3

and

ANC ≥ 2000/mm3

Every 2 weeks for 6 months

   
   

12 months of therapy

WBC ≥ 3500/mm3

Every 4 weeks ad infinitum

and

ANC ≥ 2000/mm3

Immature forms present

N/A

Repeat WBC and ANC

Discontinuation of therapy

N/A

Weekly for at least 4 weeks from day of discontinuation or until WBC ≥ 3500/mm3 and ANC ≥ 2000/mm3

Substantial drop in WBC or ANC

Single drop or cumulative drop within 3 weeks of: WBC ≥ 3000/mm3 or

1.
Repeat WBC and ANC
2.
If repeat values are: WBC 3000/mm3 to 3500 and ANC < 2000/mm3, then monitor twice weekly

ANC ≥ 1500/mm3

 

Mild leukopenia

and/or

Mild granulocytopenia

If WBC 3000 mm3 to < 3500/mm3

and/or

ANC 1500/mm3 to < 2000/mm3

Twice weekly until WBC > 3500/mm3 and

ANC > 2000/mm3 then return to previous monitoring

frequency

Moderate leukopenia

and/or

Moderate granulocytopenia

WBC 2000/mm3 to < 3000/mm3

and/or

ANC 1000/mm3 to < 1500/mm3

1.
Interrupt therapy
2.
Daily until WBC > 3000/mm3 and ANC > 1500/mm3
3.
Twice weekly until WBC > 3500/mm3 and ANC > 2000/mm3
4.
May rechallenge when WBC > 3500/mm3 and ANC > 2000/mm3
5.
If rechallenged, monitor weekly for 1 year before returning to the usual monitoring schedule of every 2 weeks for 6 months and then every 4 weeks ad infinitum

Severe leukopenia

and/or

Severe granulocytopenia

WBC count < 2000/mm3

and/or

ANC < 1000/mm3

1.
Discontinue treatment and do not rechallenge patient
2.
Monitor until normal and for at least 4 weeks from day of discontinuation as follows:
 
-Daily until WBC > 3000/mm3 and ANC > 1500/mm3
 
-Twice weekly until WBC > 3500/mm3 and ANC > 2000/mm3
 
-Weekly after WBC > 3500/mm3

Agranulocytosis

ANC < 500/mm3

1.
Discontinue treatment and do not rechallenge patient
2.
Monitor until normal and for at least 4 weeks from day of discontinuation as follows:

 
-Daily until WBC > 3000/mm3 and ANC > 1500/mm3
 
-Twice weekly until WBC > 3500/mm3 and ANC > 2000/mm3
 
-Weekly after WBC > 3500/mm3

WBC = White blood cell

ANC = Absolute neutrophil count

Decrements in WBC Count and/or ANC

Consult Table 2 above to determine how to monitor patients who experience decrements in WBC count and/or ANC at any point during treatment. Additionally, patients should be carefully monitored for flu-like symptoms or other symptoms suggestive of infection.

Nonrechallengeable Patients

If the total WBC count falls below 2000/mm3 or the ANC falls below 1000/mm3, bone-marrow aspiration should be considered to ascertain granulopoietic status and patients should not be rechallenged with Clozapine. Protective isolation with close observation may be indicated if granulopoiesis is determined to be deficient. Should evidence of infection develop, the patient should have appropriate cultures performed and an appropriate antibiotic regimen instituted.

Patients discontinued from Clozapine therapy due to significant granulopoietic suppression have been found to develop agranulocytosis upon rechallenge, often with a shorter latency on re-exposure. To reduce the chances of rechallenge occurring in patients who have experienced significant bone-marrow suppression during Clozapine therapy, a single, national master file (i.e., Nonrechallengeable Database) is confidentially maintained.

Treatment of Rechallengeable Patients

Patients may be rechallenged with Clozapine if their WBC count does not fall below 2000/mm3 and the ANC does not fall below 1000/mm3. However, analysis of the data from the CLOZARIL® National Registry suggests that patients who have an initial episode of moderate leukopenia (3000/mm3 > WBC count ≥ 2000/mm3) have up to a 12 fold increased risk of having a subsequent episode of agranulocytosis when rechallenged as compared to the full cohort of patients treated with Clozapine. Although Clozapine tablets therapy may be resumed if no symptoms of infection develop and when the WBC count rises above 3500/mm3 and the ANC rises above 2000/mm3, prescribers are strongly advised to consider whether the benefit of continuing Clozapine tablets treatment outweighs the increased risk of agranulocytosis.

Analyses of the CLOZARIL® National Registry have shown an increased risk of having a subsequent episode of granulopoietic suppression up to a year after recovery from the initial episode. Therefore, as noted in Table 2, patients must undergo weekly WBC count and ANC monitoring for 1 year following recovery from an episode of moderate leukopenia and/or moderate granulocytopenia regardless of when the episode develops. If acceptable WBC counts and ANC (WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3) have been maintained during the year of weekly monitoring, WBC counts can be monitored every 2 weeks for the next 6 months. If acceptable WBC counts and ANC (WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3) continue to be maintained during the 6 months of every 2-week monitoring, WBC counts can be monitored every 4 weeks thereafter, ad infinitum.

Interruptions in Therapy

Figure 1 provides instructions regarding re-initiating therapy and subsequently the frequency of WBC count and ANC monitoring after a period of interruption.

Figure 1. Resuming Monitoring Frequency after Interruption of Therapy

* transitions to reduce frequency of monitoring only permitted if all WBC counts ≥ 3500/mm3 and ANCs ≥ 2000/mm3.

Teva Clozapine Patient Registry Because of the Risk of Agranulocytosis

Because of the risk of agranulocytosis, Clozapine is available only through a restricted program called the Teva Clozapine Patient Registry. Under the Teva Clozapine Patient Registry, prescribers, patients, pharmacies, and distributors must enroll in the program.

Required components of the Teva Clozapine Patient Registry are:

Healthcare professionals who prescribe Clozapine must enroll in the program and comply with the Registry requirements.
Pharmacies that dispense Clozapine must enroll in the program and comply with the Registry requirements.
Routine monitoring and submission of laboratory results (WBC and ANC) is required during treatment with Clozapine [see Warnings and Precautions (5.1)].
Patients who receive Clozapine must be enrolled in a registry.

Further information is available at https://www.Clozapineregistry.com or 1-800-507-8334.

Orthostatic Hypotension, Bradycardia, and Syncope

Hypotension, bradycardia, syncope, and cardiac arrest have occurred with Clozapine treatment. The risk is highest during the initial titration period, particularly with rapid dose-escalation. These reactions can occur with the first dose, at doses as low as 12.5 mg. These reactions can be fatal. The syndrome is consistent with neurally mediated reflex bradycardia (NMRB).

Treatment must begin at a maximum dose of 12.5 mg once daily or twice daily. The total daily dose can be increased in increments of 25 mg to 50 mg per day, if well-tolerated, to a target dose of 300 mg to 450 mg per day (administered in divided doses) by the end of 2 weeks. Subsequently, the dose can be increased weekly or twice weekly, in increments of up to 100 mg. The maximum dose is 900 mg per day. Use cautious titration and a divided dosage schedule to minimize the risk of serious cardiovascular reactions [see Dosage and Administration (2.2)]. Consider reducing the dose if hypotension occurs. When restarting patients who have had even a brief interval off Clozapine (i.e., 2 days or more since the last dose), re-initiate treatment at 12.5 mg once daily or twice daily [see Dosage and Administration (2.5)].

 

Use Clozapine cautiously in patients with cardiovascular disease (history of myocardial infarction or ischemia, heart failure, or conduction abnormalities), cerebrovascular disease, and conditions which would predispose patients to hypotension (e.g., concomitant use of antihypertensives, dehydration and hypovolemia).

Seizures

Seizure has been estimated to occur in association with Clozapine use at a cumulative incidence at 1 year of approximately 5%, based on the occurrence of 1 or more seizures in 61 of 1743 patients exposed to Clozapine during its clinical testing prior to domestic marketing (i.e., a crude rate of 3.5%). The risk of seizure is dose-related. Initiate treatment with a low dose (12.5 mg), titrate slowly, and use divided dosing.

Use caution when administering Clozapine to patients with a history of seizures or other predisposing risk factors for seizure (e.g., head trauma or other CNS pathology, use of medications that lower the seizure threshold, or alcohol abuse). Because of the substantial risk of seizure associated with Clozapine use, caution patients about engaging in any activity where sudden loss of consciousness could cause serious risk to themselves or others (e.g., driving an automobile, operating complex machinery, swimming, climbing).

Myocarditis and Cardiomyopathy

Myocarditis and cardiomyopathy have occurred with the use of Clozapine. These reactions can be fatal. Discontinue Clozapine and obtain a cardiac evaluation upon suspicion of myocarditis or cardiomyopathy. Generally, patients with a history of Clozapine-associated myocarditis or cardiomyopathy should not be rechallenged with Clozapine. However, if the benefit of Clozapine treatment is judged to outweigh the potential risks of recurrent myocarditis or cardiomyopathy, the clinician may consider rechallenge with Clozapine in consultation with a cardiologist, after a complete cardiac evaluation, and under close monitoring.

Consider the possibility of myocarditis or cardiomyopathy in patients receiving Clozapine who present with chest pain, dyspnea, persistent tachycardia at rest, palpitations, fever, flu-like symptoms, hypotension, other signs or symptoms of heart failure, or electrocardiographic findings (low voltages, ST-T abnormalities, arrhythmias, right axis deviation, and poor R wave progression). Myocarditis most frequently presents within the first 2 months of Clozapine treatment. Symptoms of cardiomyopathy generally occur later than Clozapine-associated myocarditis and usually after 8 weeks of treatment. However, myocarditis and cardiomyopathy can occur at any period during treatment with Clozapine. It is common for nonspecific flu-like symptoms such as malaise, myalgia, pleuritic chest pain, and low-grade fevers to precede more overt signs of heart failure. Typical laboratory findings include elevated troponin I or T, elevated creatinine kinase-MB, peripheral eosinophilia, and elevated C-reactive protein (CRP). Chest roentgenogram may demonstrate cardiac silhouette enlargement, and cardiac imaging (echocardiogram, radionucleotide studies, or cardiac catheterization) may reveal evidence of left ventricular dysfunction.

Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10 week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality in this population. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Clozapine is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning].

. Eosinophilia

Eosinophilia, defined as a blood eosinophil count of greater than 700/mm3, has occurred with Clozapine treatment. In clinical trials, approximately 1% of patients developed eosinophilia. Clozapine-related eosinophilia usually occurs during the first month of treatment. In some patients, it has been associated with myocarditis, pancreatitis, hepatitis, colitis, and nephritis. Such organ involvement could be consistent with a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, also known as drug induced hypersensitivity syndrome (DIHS). If eosinophilia develops during Clozapine treatment, evaluate promptly for signs and symptoms of systemic reactions, such as rash or other allergic symptoms, myocarditis, or other organ-specific disease associated with eosinophilia. If Clozapine-related systemic disease is suspected, discontinue Clozapine immediately.

If a cause of eosinophilia unrelated to Clozapine is identified (e.g., asthma, allergies, collagen vascular disease, parasitic infections, and specific neoplasms), treat the underlying cause and continue Clozapine.

Clozapine-related eosinophilia has also occurred in the absence of organ involvement and can resolve without intervention. There are reports of successful rechallenge after discontinuation of Clozapine, without recurrence of eosinophilia. In the absence of organ involvement, continue Clozapine under careful monitoring. If the total eosinophil count continues to increase over several weeks in the absence of systemic disease, the decision to interrupt Clozapine therapy and rechallenge after the eosinophil count decreases should be based on the overall clinical assessment, in consultation with an internist or hematologist.

QT Interval Prolongation

QT prolongation, Torsades de Pointes and other life-threatening ventricular arrhythmias, cardiac arrest, and sudden death have occurred with Clozapine treatment. When prescribing Clozapine, consider the presence of additional risk factors for QT prolongation and serious cardiovascular reactions. Conditions that increase these risks include the following: history of QT prolongation, long QT syndrome, family history of long QT syndrome or sudden cardiac death, significant cardiac arrhythmia, recent myocardial infarction, uncompensated heart failure, treatment with other medications that cause QT prolongation, treatment with medications that inhibit the metabolism of Clozapine, and electrolyte abnormalities.

Prior to initiating treatment with Clozapine, perform a careful physical examination, medical history, and concomitant medication history. Consider obtaining a baseline ECG and serum chemistry panel. Correct electrolyte abnormalities. Discontinue Clozapine if the QTc interval exceeds 500 msec. If patients experience symptoms consistent with Torsades de Pointes, or other arrhythmias, (e.g., syncope, presyncope, dizziness, or palpitations), obtain a cardiac evaluation and discontinue Clozapine.

Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of Clozapine tablets. Drugs that cause QT prolongation include: specific antipsychotics (e.g., ziprasidone, iloperidone, chlorpromazine, thioridazine, mesoridazine, droperidol, pimozide), specific antibiotics (e.g., erythromycin, gatifloxacin, moxifloxacin, sparfloxacin), Class 1A antiarrhythmic medications (e.g., quinidine, procainamide) or Class III antiarrhythmics (e.g., amiodarone, sotalol), and others (e.g., pentamidine, levomethadyl acetate, methadone, halofantrine, mefloquine, dolasetron mesylate, probucol or tacrolimus). Clozapine is primarily metabolized by CYP isoenzymes 1A2, 2D6, and 3A4. Concomitant treatment with inhibitors of these enzymes can increase the concentration of Clozapine tablets [see Drug Interactions (7.1), Clinical Pharmacology (12.3)].

Hypokalemia and hypomagnesemia increase the risk of QT prolongation. Hypokalemia can result from diuretic therapy, diarrhea, and other causes. Use caution when treating patients at risk for significant electrolyte disturbance, particularly hypokalemia. Obtain baseline measurements of serum potassium and magnesium levels, and periodically monitor electrolytes. Correct electrolyte abnormalities before initiating treatment with Clozapine.

Metabolic Changes

Atypical antipsychotic drugs, including Clozapine have been associated with metabolic changes that can increase cardiovascular and cerebrovascular risk. These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain. While atypical antipsychotic drugs may produce some metabolic changes, each drug in the class has its own specific risk profile.

Hyperglycemia and Diabetes Mellitus

Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics including Clozapine. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse reactions is not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent, hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycemia-related adverse reactions in patients treated with atypical antipsychotics are not available.

Patients with an established diagnosis of diabetes mellitus who are started on Clozapine should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug.

In a pooled data analysis of 8 studies in adult subjects with schizophrenia, the mean changes in fasting glucose concentration in the Clozapine and chlorpromazine groups were +11 mg/dL and +4 mg/dL respectively. A higher proportion of the Clozapine group demonstrated categorical increases from baseline in fasting glucose concentrations, compared to the chlorpromazine group (Table 3). The Clozapine doses were 100 to 900 mg per day (mean modal dose: 512 mg per day). The maximum chlorpromazine dose was 1800 mg per day (mean modal dose: 1029 mg per day). The median duration of exposure was 42 days for Clozapine and chlorpromazine.

Table 3. Categorical Changes in Fasting Glucose Level in Studies in Adult Subjects with Schizophrenia

Laboratory Parameter

Category Change (at least once) from baseline

Treatment Arm

N

n (%)

Normal (< 100 mg/dL)

Clozapine

198

53 (27)

to

       

Fasting Glucose

High (≥ 126 mg/dL)

Chlorpromazine

135

14 (10)

Borderline (100 to 125 mg/dL)

Clozapine

57

24 (42)

to

       

High (≥ 126 mg/dL)

Chlorpromazine

43

12 (28)

Dyslipidemia

Undesirable alterations in lipids have occurred in patients treated with atypical antipsychotics, including Clozapine. Clinical monitoring, including baseline and periodic follow-up lipid evaluations in patients using Clozapine, is recommended.

In a pooled data analysis of 10 studies in adult subjects with schizophrenia, Clozapine treatment was associated with increases in serum total cholesterol. No data were collected on LDL and HDL cholesterol. The mean increase in total cholesterol was 13 mg/dL in the Clozapine group and 15 mg/dL in the chlorpromazine group. In a pooled data analysis of 2 studies in adult subjects with schizophrenia, Clozapine treatment was associated with increases in fasting serum triglyceride. The mean increase in fasting triglyceride was 71 mg/dL (54%) in the Clozapine group and 39 mg/dL (35%) in the chlorpromazine group (Table 4). In addition, Clozapine treatment was associated with categorical increases in serum total cholesterol and triglyceride, as illustrated in Table 5. The proportion of patients with categorical increases in total cholesterol or fasting triglyceride increased with the duration of exposure. The median duration of Clozapine and chlorpromazine exposure was 45 days and 38 days, respectively. The Clozapine dose range was 100 mg to 900 mg daily; the maximum chlorpromazine dose was 1800 mg daily.

Table 4. Mean Changes in Total Cholesterol and Triglyceride Concentration in Studies in Adult Subjects with Schizophrenia

Treatment Arm

Baseline total cholesterol concentration (mg/dL)

Change from baseline mg/dL (%)

Clozapine (N = 334)

184

+13 (7)

Chlorpromazine (N = 185)

182

+15 (8)

Baseline triglyceride concentration (mg/dL)

Change from baseline mg/dL (%)

Clozapine (N = 6)

130

+71 (54)

Chlorpromazine (N = 7)

110

+39 (35)

Table 5. Categorical Changes in Lipid Concentrations in Studies in Adult Subjects with Schizophrenia

Laboratory Parameter

Category Change (at least once) from baseline

Treatment Arm

N

n (%)

Total Cholesterol (random or fasting)

Clozapine

334

111 (33)

Increase by ≥ 40 mg/dL

Chlorpromazine

185

46 (25)

 
 

Normal (< 200 mg/dL) to

High (≥ 240 mg/dL)

Clozapine

222

18 (8)

 

Chlorpromazine

132

3 (2)

   
   

Borderline

(200 to 239 mg/dL) to

High (≥ 240 mg/dL)

Clozapine

79

30 (38)

 

Chlorpromazine

34

14 (41)

   
   

Triglycerides

(fasting)

Increase by ≥ 50 mg/dL

Clozapine

6

3 (50)

Chlorpromazine

7

3 (43)

   
   

Normal (< 150 mg/dL) to

High (≥ 200 mg/dL)

Clozapine

4

0 (0)

 

Chlorpromazine

6

2 (33)

   
   

Borderline

(≥ 150 mg/dL and < 200 mg/dL) to High (≥ 200 mg/dL)

Clozapine

1

1 (100)

 

Chlorpromazine

1

0 (0)

   
   

Weight Gain

Weight gain has occurred with the use of antipsychotics, including Clozapine. Monitor weight during treatment with Clozapine. Table 6 summarizes the data on weight gain by the duration of exposure pooled from 11 studies with Clozapine and active comparators. The median duration of exposure was 609, 728, and 42 days, in the Clozapine, olanzapine, and chlorpromazine group, respectively.

Table 6. Mean Change in Body Weight (kg) by Duration of Exposure from Studies in Adult Subjects with Schizophrenia

Metabolic parameter

Exposure duration

Clozapine

(N = 669)

Olanzapine

(N = 442)

Chlorpromazine

(N = 155)

n

Mean

n

Mean

n

Mean

Weight change from baseline

2 weeks (Day 11 to 17)

6

+0.9

3

+0.7

2

-0.5

4 weeks (Day 21 to 35)

23

+0.7

8

+0.8

17

+0.6

8 weeks (Day 49 to 63)

12

+1.9

13

+1.8

16

+0.9

12 weeks (Day 70 to 98)

17

+2.8

5

+3.1

0

0

24 weeks (Day 154 to 182)

42

-0.6

12

+5.7

0

0

48 weeks (Day 322 to 350)

3

+3.7

3

+13.7

0

0

Table 7 summarizes pooled data from 11 studies in adult subjects with schizophrenia demonstrating weight gain ≥ 7% of body weight relative to baseline. The median duration of exposure was 609, 728, and 42 days, in the Clozapine, olanzapine, and chlorpromazine group, respectively.

Table 7. Proportion of Adult Subjects in Schizophrenia Studies with Weight Gain ≥ 7% Relative to Baseline Body Weight

Weight change

Clozapine

Olanzapine

Chlorpromazine

N

669

442

155

≥ 7% (inclusive)

236 (35%)

203 (46%)

13 (8%)

Neuroleptic Malignant Syndrome

Antipsychotic drugs including Clozapine can cause a potentially fatal symptom complex referred to as Neuroleptic Malignant Syndrome (NMS). Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias). Associated findings can include elevated creatine phosphokinase (CPK), myoglobinuria, rhabdomyolysis, and acute renal failure.

The diagnostic evaluation of patients with this syndrome is complicated. It is important to consider the presence of other serious medical conditions (e.g., agranulocytosis, infection, heat stroke, primary CNS pathology, central anticholinergic toxicity, extrapyramidal symptoms, and drug fever).

The management of NMS should include (1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy, (2) intensive symptomatic treatment and medical monitoring, and (3) treatment of comorbid medical conditions. There is no general agreement about specific pharmacological treatments for NMS.

If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. NMS can recur. Monitor closely if restarting treatment with antipsychotics.

NMS has occurred with Clozapine monotherapy and with concomitant CNS-active medications, including lithium.

Fever

During Clozapine therapy, patients have experienced transient, Clozapine-related fever. The peak incidence is within the first 3 weeks of treatment. While this fever is generally benign and self-limited, it may necessitate discontinuing treatment. The fever can be associated with an increase or decrease in WBC count. Carefully evaluate patients with fever to rule out agranulocytosis or infection. Consider the possibility of NMS [see Warnings and Precautions (5.10)].

 5.12 Pulmonary Embolism

Pulmonary embolism and deep vein thrombosis have occurred in patients treated with Clozapine tablets. Consider the possibility of pulmonary embolism in patients who present with deep-vein thrombosis, acute dyspnea, chest pain, or with other respiratory signs and symptoms. Whether pulmonary embolus and deep vein thrombosis can be attributed to Clozapine or some characteristic(s) of patients is not clear.

Anticholinergic Toxicity

Clozapine has potent anticholinergic effects. Treatment with Clozapine can result in CNS and peripheral anticholinergic toxicity. Use with caution in the presence of narrow-angle glaucoma, concomitant anticholinergic medications, prostatic hypertrophy, or other conditions in which anticholinergic effects can lead to significant adverse reactions.

Treatment with Clozapine can result in gastrointestinal adverse reactions, including constipation, intestinal obstruction, fecal impaction, and paralytic ileus. Such reactions can be fatal. Constipation should be initially treated by ensuring adequate hydration and use of ancillary therapy such as bulk laxatives. Consultation with a gastroenterologist is advisable in more serious cases.

Interference with Cognitive and Motor Performance

Clozapine can cause sedation and impairment of cognitive and motor performance. Caution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that Clozapine does not affect them adversely. These reactions may be dose-related. Consider reducing the dose if they occur.

Tardive Dyskinesia

Tardive dyskinesia (TD) has occurred in patients treated with antipsychotic drugs, including Clozapine. The syndrome consists of potentially irreversible, involuntary, dyskinetic movements. The risk of TD and the likelihood that it will become irreversible are believed to increase with greater durations of treatment and higher total cumulative doses. However, the syndrome can develop after relatively brief treatment periods at low doses. Prescribe Clozapine in a manner that is most likely to minimize the risk of developing TD. Use the lowest effective dose and the shortest duration necessary to control symptoms. Periodically assess the need for continued treatment. Consider discontinuing treatment if TD occurs. However, some patients may require treatment with Clozapine despite the presence of the syndrome.

There is no known treatment for TD. However, the syndrome may remit partially or completely if treatment is discontinued. Antipsychotic treatment, itself, may suppress (or partially suppress) the signs and symptoms, and it has the potential to mask the underlying process. The effect of symptom suppression on the long-term course of TD is unknown.

Cerebrovascular Adverse Reactions

In controlled trials, elderly patients with dementia-related psychosis treated with some atypical antipsychotics had an increased risk (compared to placebo) of cerebrovascular adverse reactions (e.g., stroke, transient ischemic attack), including fatalities. The mechanism for this increased risk is not known. An increased risk cannot be excluded for Clozapine or other antipsychotics or other patient populations. Clozapine should be used with caution in patients with risk factors for cerebrovascular adverse reactions.

Recurrence of Psychosis and Cholinergic Rebound after Abrupt Discontinuation of Clozapine

If abrupt discontinuation of Clozapine is necessary (because of agranulocytosis or another medical condition, for example), monitor carefully for the recurrence of psychotic symptoms and adverse reactions related to cholinergic rebound, such as profuse sweating, headache, nausea, vomiting and diarrhea.

Adverse Reactions

The following adverse reactions are discussed in more detail in other sections of the labeling:

Agranulocytosis [see Warnings and Precautions (5.1)].
Orthostatic Hypotension, Bradycardia, and Syncope [see Warnings and Precautions (5.3)].
Seizures [see Warnings and Precautions (5.4)].
Myocarditis and Cardiomyopathy [see Warnings and Precautions (5.5)].
Increased Mortality in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions (5.6)].
Eosinophilia [see Warnings and Precautions (5.7)].
QT Interval Prolongation [see Warnings and Precautions (5.8)].
Metabolic Changes (Hyperglycemia and Diabetes Mellitus, Dyslipidemia, and Weight Gain) [see Warnings and Precautions (5.9)]  
Neuroleptic Malignant Syndrome [see Warnings and Precautions (5.10)].
Fever [see Warnings and Precautions (5.11)].
Pulmonary Embolism [see Warnings and Precautions (5.12)].
Anticholinergic Toxicity [see Warnings and Precautions (5.13)].
Interference with Cognitive and Motor Performance [see Warnings and Precautions (5.14)].
Tardive Dyskinesia [see Warnings and Precautions (5.15)].
Cerebrovascular Adverse Reactions [see Warnings and Precautions (5.16)].
Recurrence of Psychosis and Cholinergic Rebound after Abrupt Discontinuation [see Warnings and Precautions (5.17)].

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

The most commonly reported adverse reactions (≥ 5%) across Clozapine clinical trials were: CNS reactions, including sedation, dizziness/vertigo, headache, and tremor; cardiovascular reactions, including tachycardia, hypotension, and syncope; autonomic nervous system reactions, including hypersalivation, sweating, dry mouth, and visual disturbances; gastrointestinal reactions, including constipation and nausea; and fever. Table 8 summarizes the most commonly reported adverse reactions (≥ 5%) in Clozapine-treated patients (compared to chlorpromazine-treated patients) in the pivotal, 6 week, controlled trial in treatment-resistant schizophrenia.

Table 8. Common Adverse Reactions (≥ 5%) in the 6 Week, Randomized, Chlorpromazine-controlled Trial in Treatment-Resistant Schizophrenia

Adverse Reaction

Clozapine

Chlorpromazine

(N = 126)

(N = 142)

(%)

(%)

Sedation

21

13

Tachycardia

17

11

Constipation

16

12

Dizziness

14

16

Hypotension

13

38

Fever (hyperthermia)

13

4

Hypersalivation

13

1

Hypertension

12

5

Headache

10

10

Nausea/vomiting

10

12

Dry mouth

5

20

Table 9 summarizes the adverse reactions reported in Clozapine-treated patients at a frequency of 2% or greater across all Clozapine studies (excluding the 2 year InterSePT™ Study). These rates are not adjusted for duration of exposure.

Table 9. Adverse Reactions (≥ 2%) Reported in Clozapine-treated Patients (N = 842) Across all Clozapine Studies (excluding the 2 year InterSePT™ Study)
*
Rate based on population of approximately 1700 exposed during premarket clinical evaluation of Clozapine.

Body System

Clozapine

Adverse Reaction*

N = 842

Percentage of Patients

Central Nervous System

Drowsiness/Sedation

39

Dizziness/Vertigo

19

Headache

7

Tremor

6

Syncope

6

Disturbed Sleep/Nightmares

4

Restlessness

4

Hypokinesia/Akinesia

4

Agitation

4

Seizures (convulsions)

3*

Rigidity

3

Akathisia

3

Confusion

3

Fatigue

2

Insomnia

2

Cardiovascular

Tachycardia

25*

Hypotension

9

Hypertension

4

Gastrointestinal

Constipation

14

Nausea

5

Abdominal discomfort/Heartburn

4

Nausea/Vomiting

3

Vomiting

3

Diarrhea

2

Urogenital

Urinary abnormalities

2

Autonomic Nervous System

Salivation

31

Sweating

6

Dry mouth

6

Visual disturbances

5

Skin

Rash

2

Hemic/Lymphatic

Leukopenia/Decreased WBC/

Neutropenia

3

Miscellaneous

Fever

5

Weight Gain

4

Table 10 summarizes the most commonly reported adverse reactions (≥ 10% of the Clozapine or olanzapine group) in the InterSePT™ Study. This was an adequate and well-controlled, 2 year study evaluating the efficacy of Clozapine relative to olanzapine in reducing the risk of suicidal behavior in patients with schizophrenia or schizoaffective disorder. The rates are not adjusted for duration of exposure.

Table 10. Incidence of Adverse Reactions in Patients Treated with Clozapine or Olanzapine in the InterSePT™ Study (> 10% in the Clozapine or olanzapine group)

Clozapine

Olanzapine

N = 479

N = 477

Adverse Reactions

% Reporting

% Reporting

Salivary hypersecretion

48

6

Somnolence

46

25

Weight increased

31

56

Dizziness (excluding vertigo)

27

12

Constipation

25

10

Insomnia

20

33

Nausea

17

10

Vomiting

17

9

Dyspepsia

14

8

Dystonia

Class effect: Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of Clozapine. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Central Nervous System

Delirium, EEG abnormal, myoclonus, paresthesia, possible cataplexy, status epilepticus, obsessive compulsive symptoms, and post-discontinuation cholinergic rebound adverse reactions.

Cardiovascular System

Atrial or ventricular fibrillation, ventricular tachycardia, QT interval prolongation, Torsades de Pointes, myocardial infarction, cardiac arrest, and periorbital edema.

Gastrointestinal System

Acute pancreatitis, dysphagia, salivary gland swelling, colitis.

Hepatobiliary System

Cholestasis, hepatitis, jaundice, hepatotoxicity, hepatic steatosis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, liver injury (hepatic, cholestatic, and mixed), and liver failure.

Immune System Disorders

Angioedema, leukocytoclastic vasculitis.

Urogenital System

Acute interstitial nephritis, nocturnal enuresis, priapism, and renal failure.

Skin and Subcutaneous Tissue Disorders

Hypersensitivity reactions: photosensitivity, vasculitis, erythema multiforme, skin pigmentation disorder, and Stevens-Johnson syndrome.

Musculoskeletal System and Connective Tissue Disorders

Myasthenic syndrome, rhabdomyolysis, and systemic lupus erythematosus.

Respiratory System

Aspiration, pleural effusion, pneumonia, lower respiratory tract infection.

Hemic and Lymphatic System

Deep-vein thrombosis, elevated hemoglobin/hematocrit, erythrocyte sedimentation rate (ESR) increased, sepsis, thrombocytosis, and thrombocytopenia.

Vision Disorders

Narrow-angle glaucoma.

Miscellaneous

Creatine phosphokinase elevation, hyperuricemia, hyponatremia, and weight loss.

Drug Interactions

Potential for Other Drugs to Affect Clozapine

Clozapine is a substrate for many cytochrome P450 isozymes, in particular CYP1A2, CYP3A4, and CYP2D6. Use caution when administering Clozapine tablets concomitantly with drugs that are inducers or inhibitors of these enzymes.

CYP1A2 Inhibitors

Concomitant use of Clozapine tablets and CYP1A2 inhibitors can increase plasma levels of Clozapine, potentially resulting in adverse reactions. Reduce the Clozapine tablets dose to one third of the original dose when Clozapine tablets are coadministered with strong CYP1A2 inhibitors (e.g., fluvoxamine, ciprofloxacin, or enoxacin). The Clozapine tablets dose should be increased to the original dose when coadministration of strong CYP1A2 inhibitors is discontinued [see Dosage and Administration (2.6), Clinical Pharmacology (12.3)].

Moderate or weak CYP1A2 inhibitors include oral contraceptives and caffeine. Monitor patients closely when Clozapine tablets are coadministered with these inhibitors. Consider reducing the Clozapine tablets dosage if necessary [see Dosage and Administration (2.6)].

CYP2D6 and CYP3A4 Inhibitors

Concomitant treatment with Clozapine tablets and CYP2D6 or CYP3A4 inhibitors (e.g., cimetidine, escitalopram, erythromycin, paroxetine, bupropion, fluoxetine, quinidine, duloxetine, terbinafine, or sertraline) can increase Clozapine levels and lead to adverse reactions [see Clinical Pharmacology (12.3)]. Use caution and monitor patients closely when using such inhibitors. Consider reducing the Clozapine tablets dose [see Dosage and Administration (2.6)].

CYP1A2 and CYP3A4 Inducers

Concomitant treatment with drugs that induce CYP1A2 or CYP3A4 can decrease the plasma concentration of Clozapine, resulting in decreased effectiveness of Clozapine tablets. Tobacco smoke is a moderate inducer of CYP1A2. Strong CYP3A4 inducers include carbamazepine, phenytoin, St. John’s wort, and rifampin. It may be necessary to increase the Clozapine tablets dose if used concomitantly with inducers of these enzymes. However, concomitant use of Clozapine tablets and strong CYP3A4 inducers is not recommended [see Dosage and Administration (2.6)].

Consider reducing the Clozapine tablets dosage when discontinuing coadministered enzyme inducers; because discontinuation of inducers can result in increased Clozapine plasma levels and an increased risk of adverse reactions [see Dosage and Administration (2.6)].

Drugs that Cause QT Interval Prolongation

Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of Clozapine. Drugs that cause QT prolongation include: specific antipsychotics (e.g., ziprasidone, iloperidone, chlorpromazine, thioridazine, mesoridazine, droperidol, and pimozide), specific antibiotics (e.g., erythromycin, gatifloxacin, moxifloxacin, sparfloxacin), Class 1A antiarrhythmics (e.g., quinidine, procainamide) or Class III antiarrhythmics (e.g., amiodarone, sotalol), and others (e.g., pentamidine, levomethadyl acetate, methadone, halofantrine, mefloquine, dolasetron mesylate, probucol or tacrolimus) [see Warnings and Precautions (5.8)].

Potential for Clozapine to Affect Other Drugs

Concomitant use of Clozapine with other drugs metabolized by CYP2D6 can increase levels of these CYPD26 substrates. Use caution when coadministering Clozapine with other drugs that are metabolized by CYP2D6. It may be necessary to use lower doses of such drugs than usually prescribed. Such drugs include specific antidepressants, phenothiazines, carbamazepine, and Type 1C antiarrhythmics (e.g., propafenone, flecainide, and encainide).

USE IN SPECIFIC POPULATIONS

Pregnancy

Teratogenic Effects

Pregnancy Category B

Risk Summary

There are no adequate or well-controlled studies of Clozapine in pregnant women.

Reproduction studies have been performed in rats and rabbits at doses up to 0.4 and 0.9 times, respectively, the maximum recommended human dose (MRHD) of 900 mg/day on a mg/m2 body surface area basis. The studies revealed no evidence of impaired fertility or harm to the fetus due to Clozapine. Because animal reproduction studies are not always predictive of human response, Clozapine tablets should be used during pregnancy only if clearly needed.

Clinical Considerations

Consider the risk of exacerbation of psychosis when discontinuing or changing treatment with antipsychotic medications during pregnancy and postpartum. Consider early screening for gestational diabetes for patients treated with antipsychotic medications [see Warnings and Precautions (5.9)]. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. Monitor neonates for symptoms of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding difficulties. The severity of complications can vary from self-limited symptoms to some neonates requiring intensive care unit support and prolonged hospitalization.

Animal Data

In embryofetal developmental studies, Clozapine had no effects on maternal parameters, litter sizes, or fetal parameters when administered orally to pregnant rats and rabbits during the period of organogenesis at doses up to 0.4 and 0.9 times, respectively, the MRHD of 900 mg/day on a mg/m2 body surface area basis.

In peri/postnatal developmental studies, pregnant female rats were administered Clozapine over the last third of pregnancy and until day 21 postpartum. Observations were made on fetuses at birth and during the postnatal period; the offspring were allowed to reach sexual maturity and mated. Clozapine caused a decrease in maternal body weight but had no effects on litter size or body weights of either F1or F2 generations at doses up to 0.4 times the MRHD of 900 mg/day on a mg/m2 body surface area basis.

Nursing Mothers

Clozapine is present in human milk. Because of the potential for serious adverse reactions in nursing infants from Clozapine, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Geriatric Use

There have not been sufficient numbers of geriatric patients in clinical studies utilizing Clozapine to determine whether those over 65 years of age differ from younger subjects in their response to Clozapine.

Orthostatic hypotension and tachycardia can occur with Clozapine treatment [see Boxed Warning and Warnings and Precautions (5.3)]. Elderly patients, particularly those with compromised cardiovascular functioning, may be more susceptible to these effects.

Elderly patients may be particularly susceptible to the anticholinergic effects of Clozapine, such as urinary retention and constipation [see Warnings and Precautions (5.13)].

 

Carefully select Clozapine doses in elderly patients, taking into consideration their greater frequency of decreased hepatic, renal, or cardiac function, as well as other concomitant disease and other drug therapy. Clinical experience suggests that the prevalence of tardive dyskinesia appears to be highest among the elderly; especially elderly women [see Warnings and Precautions (5.15)].

Patients with Renal or Hepatic Impairment

Dose reduction may be necessary in patients with significant impairment of renal or hepatic function. Clozapine concentrations may be increased in these patients, because Clozapine is almost completely metabolized and then excreted [see Dosage and Administration (2.7), Clinical Pharmacology (12.3)].

CYP2D6 Poor Metabolizers

Dose reduction may be necessary in patients who are CYP2D6 poor metabolizers. Clozapine concentrations may be increased in these patients, because Clozapine is almost completely metabolized and then excreted [see Dosage and Administration (2.7), Clinical Pharmacology (12.3)].

Overdosage

Overdosage Experience

The most commonly reported signs and symptoms associated with Clozapine overdose are: sedation, delirium, coma, tachycardia, hypotension, respiratory depression or failure; and hypersalivation. There are reports of aspiration pneumonia, cardiac arrhythmias, and seizure. Fatal overdoses have been reported with Clozapine, generally at doses above 2500 mg. There have also been reports of patients recovering from overdoses well in excess of 4 g.

Management of Overdosage

For the most up-to-date information on the management of Clozapine overdosage, contact a certified Regional Poison Control Center (1-800-222-1222). Telephone numbers of certified Regional Poison Control Centers are listed in the Physicians’ Desk Reference®, a registered trademark of Thomson PDR. Establish and maintain an airway; ensure adequate oxygenation and ventilation. Monitor cardiac status and vital signs. Use general symptomatic and supportive measures. There are no specific antidotes for Clozapine.

In managing overdosage, consider the possibility of multiple-drug involvement.

Clozapine Description

Clozapine tablets USP, an atypical antipsychotic drug, are a tricyclic dibenzodiazepine derivative. The chemical name of Clozapine, USP is 8-chloro-11-(4-methyl-1-piperazinyl)-5H-dibenzo [b,e] [1,4] diazepine and it has the following structural formula:

Clozapine, USP is a yellow, crystalline powder, very slightly soluble in water. Each tablet, for oral administration, contains 25 mg, 50 mg, 100 mg, or 200 mg Clozapine, USP. In addition, each tablet contains the following inactive ingredients: colloidal silicon dioxide, corn starch, magnesium stearate, povidone, pregelatinized corn starch, and talc. Additionally, the 25 mg and 100 mg tablets contain lactose monohydrate and the 50 mg and 200 mg tablets contain anhydrous lactose and crospovidone.

Clozapine - Clinical Pharmacology

Mechanism of Action

The mechanism of action of Clozapine is unknown. However, it has been proposed that the therapeutic efficacy of Clozapine in schizophrenia is mediated through antagonism of the dopamine type 2 (D2) and the serotonin type 2A (5-HT2A) receptors. Clozapine tablets also act as an antagonist at adrenergic, cholinergic, histaminergic and other dopaminergic and serotonergic receptors.

Pharmacodynamics

Clozapine demonstrated binding affinity to the following receptors: histamine H1 (Ki 1.1 nM), adrenergic α1A (Ki 1.6 nM), serotonin 5-HT6 (Ki 4 nM), serotonin 5-HT2A (Ki 5.4 nM), muscarinic M1 (Ki 6.2 nM), serotonin 5-HT7 (Ki 6.3 nM), serotonin 5-HT2C (Ki 9.4 nM), dopamine D4 (Ki 24 nM), adrenergic α2A (Ki 90 nM), serotonin 5-HT3 (Ki 95 nM), serotonin 5-HT1A (Ki 120 nM), dopamine D2 (Ki 160 nM), dopamine D1 (Ki 270 nM), dopamine D5 (Ki 454 nM), and dopamine D3 (Ki 555 nM).

Clozapine causes little or no prolactin elevation.

Clinical electroencephalogram (EEG) studies demonstrated that Clozapine increases delta and theta activity and slows dominant alpha frequencies. Enhanced synchronization occurs. Sharp wave activity and spike and wave complexes may also develop. Patients have reported an intensification of dream activity during Clozapine therapy. REM sleep was found to be increased to 85% of the total sleep time. In these patients, the onset of REM sleep occurred almost immediately after falling asleep.

Pharmacokinetics

Absorption

In man, Clozapine tablets (25 mg and 100 mg) are equally bioavailable relative to a Clozapine solution. Following oral administration of Clozapine 100 mg twice daily, the average steady-state peak plasma concentration was 319 ng/mL (range: 102 to 771 ng/mL), occurring at the average of 2.5 hours (range: 1 to 6 hours) after dosing. The average minimum concentration at steady state was 122 ng/mL (range: 41 to 343 ng/mL), after 100 mg twice daily dosing. Food does not appear to affect the systemic bioavailability of Clozapine. Thus, Clozapine may be administered with or without food.

Distribution

Clozapine is approximately 97% bound to serum proteins. The interaction between Clozapine and other highly protein-bound drugs has not been fully evaluated but may be important [see Drug Interactions (7)].

 Metabolism and Excretion

Clozapine is almost completely metabolized prior to excretion, and only trace amounts of unchanged drug are detected in the urine and feces. Clozapine is a substrate for many cytochrome P450 isozymes, in particular CYP1A2, CYP2D6, and CYP3A4. Approximately 50% of the administered dose is excreted in the urine and 30% in the feces. The demethylated, hydroxylated, and N-oxide derivatives are components in both urine and feces. Pharmacological testing has shown the desmethyl metabolite (norClozapine) to have only limited activity, while the hydroxylated and N-oxide derivatives were inactive. The mean elimination half-life of Clozapine after a single 75 mg dose was 8 hours (range: 4 to 12 hours), compared to a mean elimination half-life of 12 hours (range: 4 to 66 hours), after achieving steady state with 100 mg twice daily dosing.

A comparison of single-dose and multiple-dose administration of Clozapine demonstrated that the elimination half-life increased significantly after multiple dosing relative to that after single-dose administration, suggesting the possibility of concentration-dependent pharmacokinetics. However, at steady state, approximately dose-proportional changes with respect to area under the curve (AUC), peak, and minimum Clozapine plasma concentrations were observed after administration of 37.5, 75, and 150 mg twice daily.

Drug-Drug Interaction Studies

Fluvoxamine

A pharmacokinetic study was conducted in 16 schizophrenic patients who received Clozapine under steady-state conditions. After coadministration of fluvoxamine for 14 days, mean trough concentrations of Clozapine and its metabolites, N-desmethylClozapine and Clozapine N-oxide, were elevated about 3 fold compared to baseline steady-state concentrations.

Paroxetine, Fluoxetine, and Sertraline

In a study of schizophrenic patients (n = 14) who received Clozapine under steady-state conditions, coadministration of paroxetine produced only minor changes in the levels of Clozapine and its metabolites. However, other published reports describe modest elevations (less than 2 fold) of Clozapine and metabolite concentrations when Clozapine was taken with paroxetine, fluoxetine, and sertraline.

Specific Population Studies

Renal or Hepatic Impairment

No specific pharmacokinetic studies were conducted to investigate the effects of renal or hepatic impairment on the pharmacokinetics of Clozapine. Higher Clozapine plasma concentrations are likely in patients with significant renal or hepatic impairment when given usual doses.

CYP2D6 Poor Metabolizers

A subset (3% to 10%) of the population has reduced activity of CYP2D6 (CYP2D6 poor metabolizers). These individuals may develop higher than expected plasma concentrations of Clozapine when given usual doses.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

No carcinogenic potential was demonstrated in long-term studies in mice and rats at doses up to 0.3 times and 0.4 times, respectively, the maximum recommended human dose (MRHD) of 900 mg/day on a mg/m2 body surface area basis.

Mutagenesis

Clozapine was not genotoxic when tested in the following gene mutation and chromosomal aberration tests: the bacterial Ames test, the in vitro mammalian V79 in Chinese hamster cells, the in vitro unscheduled DNA synthesis in rat hepatocytes or the in vivo micronucleus assay in mice.

Impairment of Fertility

Clozapine had no effect on any parameters of fertility, pregnancy, fetal weight or postnatal development when administered orally to male rats 70 days before mating and to female rats for 14 days before mating at doses up to 0.4 times the MRHD of 900 mg/day on a mg/m2 body surface area basis.

Clinical Studies

Treatment Resistant Schizophrenia

The efficacy of Clozapine in treatment-resistant schizophrenia was established in a multicenter, randomized, double-blind, active-controlled (chlorpromazine) study in patients with a DSM-III diagnosis of schizophrenia who had inadequate responses to at least 3 different antipsychotics (from at least 2 different chemical classes) during the preceding 5 years. The antipsychotic trials must have been judged adequate; the antipsychotic dosages must have been equivalent to or greater than 1000 mg per day of chlorpromazine for a period of at least 6 weeks, each without significant reduction of symptoms. There must have been no period of good functioning within the preceding 5 years. Patients must have had a baseline score of at least 45 on the investigator-rated Brief Psychiatric Rating Scale (BPRS). On the 18-item BPRS, 1 indicates the absence of symptoms, and 7 indicates severe symptoms; the maximum potential total BPRS score is 126. At baseline, the mean BPRS score was 61. In addition, patients must have had a score of at least 4 on at least 2 of the following 4 individual BPRS items: conceptual disorganization, suspiciousness, hallucinatory behavior, and unusual thought content. Patients must have had a Clinical Global Impressions–Severity Scale score of at least 4 (moderately ill).

In the prospective, lead-in phase of the trial, all patients (N = 305) initially received single-blind treatment with haloperidol (the mean dose was 61 mg per day) for 6 weeks. More than 80% of patients completed the 6 week trial. Patients with an inadequate response to haloperidol (n = 268) were randomized to double-blind treatment with Clozapine (N = 126) or chlorpromazine (N = 142). The maximum daily Clozapine dose was 900 mg; the mean daily dose was > 600 mg. The maximum daily chlorpromazine dose was 1800 mg; the mean daily dose was > 1200 mg.

The primary endpoint was treatment response, predefined as a decrease in BPRS score of at least 20% and either (1) a CGI-S score of ≤ 3 (mildly ill), or (2) a BPRS score of ≤ 35, at the end of 6 weeks of treatment. Approximately 88% of patients from the Clozapine and chlorpromazine groups completed the 6 week trial. At the end of 6 weeks, 30% of the Clozapine group responded to treatment, and 4% of the chlorpromazine group responded to treatment. The difference was statistically significant (p < 0.001). The mean change in total BPRS score was -16 and -5 in the Clozapine and chlorpromazine group, respectively; the mean change in the 4 key BPRS item scores was -5 and -2 in the Clozapine and chlorpromazine group, respectively; and the mean change in CGI-S score was -1.2 and -0.4, in the Clozapine and chlorpromazine group, respectively. These changes in the Clozapine group were statistically significantly greater than in the chlorpromazine group (p < 0.001 in each analysis).

Recurrent Suicidal Behavior in Schizophrenia or Schizoaffective Disorder

The effectiveness of Clozapine in reducing the risk of recurrent suicidal behavior was assessed in the International Suicide Prevention Trial (InterSePT™). This was a prospective, randomized, open-label, active-controlled, multicenter, international, parallel-group comparison of Clozapine versus olanzapine (Zyprexa®) in 956 patients with schizophrenia or schizoaffective disorder (DSM-IV) who were judged to be at risk for recurrent suicidal behavior. Only about one-fourth of these patients (27%) were considered resistant to standard antipsychotic drug treatment. To enter the trial, patients must have met 1 of the following criteria:

They had attempted suicide within the 3 years prior to their baseline evaluation.
They had been hospitalized to prevent a suicide attempt within the 3 years prior to their baseline evaluation.
They demonstrated moderate-to-severe suicidal ideation with a depressive component within 1 week prior to their baseline evaluation.
They demonstrated moderate-to-severe suicidal ideation accompanied by command hallucinations to do self-harm within 1 week prior to their baseline evaluation.

Dosing regimens for each treatment group were determined by individual investigators and were individualized by patient. Dosing was flexible, with a dose range of 200 to 900 mg/day for Clozapine and 5 to 20 mg/day for olanzapine. For the 956 patients who received Clozapine or olanzapine in this study, there was extensive use of concomitant psychotropics: 84% with antipsychotics, 65% with anxiolytics, 53% with antidepressants, and 28% with mood stabilizers. There was significantly greater use of concomitant psychotropic medications among the patients in the olanzapine group.

The primary efficacy measure was time to (1) a significant suicide attempt, including a completed suicide; (2) hospitalization due to imminent suicide risk, including increased level of surveillance for suicidality for patients already hospitalized; or (3) worsening of suicidality severity as demonstrated by “much worsening” or “very much worsening” from baseline in the Clinical Global Impression of Severity of Suicidality as assessed by the Blinded Psychiatrist (CGI-SS-BP) scale. A determination of whether or not a reported event met criterion 1 or 2 above was made by the Suicide Monitoring Board (SMB), a group of experts blinded to patient data.

A total of 980 patients were randomized to the study and 956 received study medication. Sixty-two percent of the patients were diagnosed with schizophrenia, and the remainder (38%) were diagnosed with schizoaffective disorder. Only about one-fourth of the total patient population (27%) was identified as “treatment-resistant” at baseline. There were more males than females in the study (61% of all patients were male). The mean age of patients entering the study was 37 years of age (range 18 to 69). Most patients were Caucasian (71%), 15% were black, 1% were Asian, and 13% were classified as being of “other” races.

Patients treated with Clozapine had a statistically significant longer delay in the time to recurrent suicidal behavior in comparison with olanzapine. This result should be interpreted only as evidence of the effectiveness of Clozapine in delaying time to recurrent suicidal behavior and not a demonstration of the superior efficacy of Clozapine over olanzapine.

The probability of experiencing (1) a significant suicide attempt, including a completed suicide, or (2) hospitalization because of imminent suicide risk, including increased level of surveillance for suicidality for patients already hospitalized, was lower for Clozapine patients than for olanzapine patients at Week 104: Clozapine 24% versus olanzapine 32%; 95% CI of the difference: 2%, 14% (Figure 2).

Figure 2. Cumulative Probability of a Significant Suicide Attempt or Hospitalization to Prevent Suicide in Patients with Schizophrenia or Schizoaffective Disorder at High Risk of Suicidality

How Supplied/Storage and Handling

How Supplied

Clozapine Tablets USP are available as pale yellow, round tablets, debossed and “4359" on one side and "25" and a bisect on the other side, containing 25 mg Clozapine, USP.

NDC 0093-4359-01 25 mg packaged in bottles of 100 tablets

NDC 0093-4359-05 25 mg packaged in bottles of 500 tablets

NDC 0093-4359-93 25 mg packaged in unit-dose boxes of 100 tablets

Clozapine Tablets USP are available as pale yellow, round, flat-faced, beveled-edge tablets, debossed and “4404" on one side and "50" and a bisect on the other side, containing 50 mg Clozapine, USP.

NDC 0093-4404-01 50 mg packaged in bottles of 100 tablets

NDC 0093-4404-05 50 mg packaged in bottles of 500 tablets

NDC 0093-4404-93 50 mg packaged in unit-dose boxes of 100 tablets

Clozapine Tablets USP are available as pale yellow, round, flat-faced, beveled-edge tablets, debossed and “7772" on one side and "100" and a bisect on the other side, containing 100 mg Clozapine, USP.

NDC 0093-7772-01 100 mg packaged in bottles of 100 tablets

NDC 0093-7772-05 100 mg packaged in bottles of 500 tablets

NDC 0093-7772-93 100 mg packaged in unit-dose boxes of 100 tablets

Clozapine Tablets USP are available as pale yellow, oval-shaped, biconvex tablets, debossed and “4405” on one side and “200” and a deep bisect on the other side, containing 200 mg Clozapine, USP.

NDC 0093-4405-01 200 mg packaged in bottles of 100 tablets

NDC 0093-4405-05 200 mg packaged in bottles of 500 tablets

NDC 0093-4405-93 200 mg packaged in unit-dose boxes of 100 tablets

Storage and Handling

Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature].

Dispense in a tight container as defined in the USP, with a child-resistant closure (as required).

KEEP THIS AND ALL MEDICATIONS OUT OF THE REACH OF CHILDREN.

Patient Counseling Information

Discuss the following issues with patients and caregivers:

Agranulocytosis:Prior to initiating treatment, educate patients and caregivers about the significant risk of developing agranulocytosis. Advise them to immediately report the appearance of signs or symptoms consistent with agranulocytosis or infection (e.g., fever; mucus membrane ulcers; skin, pharyngeal, vaginal, urinary, or pulmonary infection; or extreme weakness or lethargy) at any time during Clozapine therapy [see Boxed Warning and Warnings and Precautions (5.1)].
 
  -Inform patients and caregivers that Clozapine will be made available only through a special program (Teva Clozapine Patient Registry) designed to ensure the required blood monitoring, in order to reduce the risk of developing agranulocytosis. Inform patients and caregivers the WBC count and ANC will be monitored as follows:
 
• Weekly blood tests are required for the first 6 months.
 
• If acceptable WBC counts and ANCs (WBC count ≥ 3500/mm3 and ANC ≥ 2000/mm3) have been maintained during the first 6 months of continuous therapy, then WBC counts and ANCs can be monitored every 2 weeks for the next 6 months.
 
• Thereafter, if acceptable WBC counts and ANCs have been maintained during the second 6 months of continuous therapy, WBC counts and ANCs can be monitored every 4 weeks.
Orthostatic Hypotension, Bradycardia, and Syncope:Inform patients and caregivers about the risk of orthostatic hypotension and syncope, especially during the period of initial dose titration. Instruct them to strictly follow the clinician’s instructions for dosage and administration. Advise patients to consult their clinician immediately if they feel faint, lose consciousness or have signs or symptoms suggestive of bradycardia or arrhythmia [see Dosage and Administration (2.2) and Warnings and Precautions (5.3)].
Seizures:Inform patients and caregivers about the significant risk of seizure during Clozapine treatment. Caution them about driving and any other potentially hazardous activity while taking Clozapine [see Warnings and Precautions (5.4)].
QT Interval Prolongation: Advise patients to consult their clinician immediately if they feel faint, lose consciousness or have signs or symptoms suggestive of arrhythmia. Instruct patients to not take Clozapine with other drugs that cause QT interval prolongation. Instruct patients to inform their clinicians that they are taking Clozapine before any new drug [see Warnings and Precautions (5.8.), Drug Interactions (7.1)].
Metabolic Changes (hyperglycemia and diabetes mellitus, dyslipidemia, weight gain):Educate patients and caregivers about the risk of metabolic changes and the need for specific monitoring. The risks include hyperglycemia and diabetes mellitus, dyslipidemia, weight gain, and cardiovascular reactions. Educate patients and caregivers about the symptoms of hyperglycemia (high blood sugar) and diabetes mellitus (e.g., polydipsia, polyuria, polyphagia, and weakness). Monitor all patients for these symptoms. Patients who are diagnosed with diabetes or have risk factors for diabetes (obesity, family history of diabetes) should have their fasting blood glucose monitored before beginning treatment and periodically during treatment. Patients who develop symptoms of hyperglycemia should have assessments of fasting glucose. Clinical monitoring of weight is recommended [see Warnings and Precautions (5.9)].
Interference with Cognitive and Motor Performance:Because Clozapine may have the potential to impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that Clozapine therapy does not affect them adversely [see Warnings and Precautions (5.14)].
Missed Doses and Re-initiating Treatment:Inform patients and caregivers that if the patient misses taking Clozapine for more than 2 days, they should not restart their medication at the same dosage but should contact their physician for dosing instructions adversely [see Dosage and Administration (2.5) and Warnings and Precautions (5.3)].
Pregnancy:Patients and caregivers should notify the clinician if the patient becomes pregnant or intends to become pregnant during therapy [see Use in Specific Populations (8.1)].
Nursing:Advise patients and caregivers that the patient should not breastfeed an infant if they are taking Clozapine [see Use in Specific Populations (8.3)].
Concomitant Medication:Advise patients to inform their healthcare provider if they are taking, or plan to take, any prescription or over-the-counter drugs; there is a potential for significant drug-drug interactions [see Dosage and Administration (2.6), Drug Interactions (7.1)].

All brand names listed are the registered trademarks of their respective owners and are not trademarks of Teva Pharmaceuticals USA.

Manufactured In Israel By:

TEVA PHARMACEUTICAL IND. LTD.

Jerusalem, 9777402, Israel

Manufactured For:

TEVA PHARMACEUTICALS USA, INC.

North Wales, PA 19454

Rev. M 10/2014

Package/Label Display Panel

Clozapine Tablets USP 25mg, 100s Unit-Dose Label Text

NDC 0093-4359-93

Clozapine
Tablets USP
25 mg

Each tablet contains

Clozapine, USP 25 mg

Rx only

100 UNIT-DOSE TABLETS (10 x 10)

TEVA

Package/Label Display Panel

Clozapine Tablets USP 50mg, 100s Unit-Dose Label Text

NDC 0093-4404-93

Clozapine
Tablets USP
50 mg

Each tablet contains

Clozapine, USP 50 mg

Rx only

100 UNIT-DOSE TABLETS (10 x 10)

TEVA

Package/Label Display Panel

Clozapine Tablets USP 100mg, 100s Unit-Dose Label Text

NDC 0093-7772-93

Clozapine
Tablets USP
100 mg

Each tablet contains

Clozapine, USP 100 mg

Rx only

100 UNIT-DOSE TABLETS (10 x 10)

TEVA

Package/Label Display Panel

Clozapine Tablets USP 200mg, 100s Unit-Dose Label Text

NDC 0093-4405-93

Clozapine
Tablets USP
200 mg

Each tablet contains

Clozapine, USP 200 mg

Rx only

100 UNIT-DOSE TABLETS (10 x 10)

TEVA

Clozapine 
Clozapine tablet
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0093-4359
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Clozapine (Clozapine) Clozapine 25 mg
Inactive Ingredients
Ingredient Name Strength
SILICON DIOXIDE  
STARCH, CORN  
MAGNESIUM STEARATE  
POVIDONE K90  
TALC  
LACTOSE MONOHYDRATE  
Product Characteristics
Color YELLOW (pale yellow) Score 2 pieces
Shape ROUND Size 7mm
Flavor Imprint Code 4359;25
Contains         
Packaging
# Item Code Package Description
1 NDC:0093-4359-01 100 TABLET in 1 BOTTLE
2 NDC:0093-4359-05 500 TABLET in 1 BOTTLE
3 NDC:0093-4359-93 100 BLISTER PACK in 1 BOX, UNIT-DOSE
3 NDC:0093-4359-19 1 TABLET in 1 BLISTER PACK
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA074949 05/10/2007
Clozapine 
Clozapine tablet
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0093-4404
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Clozapine (Clozapine) Clozapine 50 mg
Inactive Ingredients
Ingredient Name Strength
SILICON DIOXIDE  
STARCH, CORN  
MAGNESIUM STEARATE  
POVIDONE K30  
TALC  
ANHYDROUS LACTOSE  
CROSPOVIDONE  
Product Characteristics
Color YELLOW (pale yellow) Score 2 pieces
Shape ROUND Size 8mm
Flavor Imprint Code 4404;50
Contains         
Packaging
# Item Code Package Description
1 NDC:0093-4404-01 100 TABLET in 1 BOTTLE
2 NDC:0093-4404-05 500 TABLET in 1 BOTTLE
3 NDC:0093-4404-93 100 BLISTER PACK in 1 BOX, UNIT-DOSE
3 NDC:0093-4404-19 1 TABLET in 1 BLISTER PACK
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA076809 03/19/2007
Clozapine 
Clozapine tablet
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0093-7772
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Clozapine (Clozapine) Clozapine 100 mg
Inactive Ingredients
Ingredient Name Strength
SILICON DIOXIDE  
STARCH, CORN  
MAGNESIUM STEARATE  
POVIDONE K90  
TALC  
LACTOSE MONOHYDRATE  
Product Characteristics
Color YELLOW (pale yellow) Score 2 pieces
Shape ROUND Size 9mm
Flavor Imprint Code 7772;100
Contains         
Packaging
# Item Code Package Description
1 NDC:0093-7772-01 100 TABLET in 1 BOTTLE
2 NDC:0093-7772-05 500 TABLET in 1 BOTTLE
3 NDC:0093-7772-93 100 BLISTER PACK in 1 BOX, UNIT-DOSE
3 NDC:0093-7772-19 1 TABLET in 1 BLISTER PACK
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA074949 09/18/2009
Clozapine 
Clozapine tablet
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0093-4405
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Clozapine (Clozapine) Clozapine 200 mg
Inactive Ingredients
Ingredient Name Strength
SILICON DIOXIDE  
STARCH, CORN  
MAGNESIUM STEARATE  
POVIDONE K30  
TALC  
ANHYDROUS LACTOSE  
CROSPOVIDONE  
Product Characteristics
Color YELLOW (pale yellow) Score 2 pieces
Shape OVAL (oval-shaped) Size 14mm
Flavor Imprint Code 4405;200
Contains         
Packaging
# Item Code Package Description
1 NDC:0093-4405-01 100 TABLET in 1 BOTTLE
2 NDC:0093-4405-05 500 TABLET in 1 BOTTLE
3 NDC:0093-4405-93 100 BLISTER PACK in 1 BOX, UNIT-DOSE
3 NDC:0093-4405-19 1 TABLET in 1 BLISTER PACK
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA076809 05/15/2007
Labeler - Teva Pharmaceuticals USA Inc (001627975)
Revised: 12/2014
 
Teva Pharmaceuticals USA Inc
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