CPCP: Clozapine and Bowel Obstruction by A Medical Student

Comin’ at ya with another great Clinical Problems in Consultation Psychiatry (CPCP) presentation by a stellar medical student, Mark Bevill. This one is on a very important complication of clozapine treatment, constipation, which can lead to potentially life-threatening bowel obstruction.

This is another one of those clozapine adverse events for which there is no specific Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program. The only Clozapine REMS Program there is for severe neutropenia. On the other hand, psychiatrists and internists need to be on the lookout for other important side effects of clozapine, which can make it a very challenging drug to use even though it’s very effective for treatment-resistant schizophrenia.

This condition used to be called Clozapine Induced Gastrointestinal Hypomotility (CIGH) and it should be familiar to every clinician prescribing clozapine because the complications, such as ileus and bowel obstruction, can be fatal, possibly in about 7% of cases according to Mark Bevill’s literature search.

It’s good to know there are ways to prevent this problem; mainly by making sure the patient is moving his bowels. An effective bowel regimen is key. Patients don’t have to necessarily be obsessional about their stools and get too focused on things like the Bristol Stool Chart.

They and their doctors do need to be mindful about their bowel movements, though, and while I couldn’t find anything in PubMed about mindfulness meditation for constipation per se, there was a study which found Mindfulness Based Stress Reduction (MBSR) to be helpful over treatment as usual for women with irritable bowel syndrome, a condition in which one of the symptoms is often constipation:

Zernicke, K. A., et al. (2013). “Mindfulness-Based Stress Reduction for the Treatment of Irritable Bowel Syndrome Symptoms: A Randomized Wait-list Controlled Trial.” International Journal of Behavioral Medicine 20(3): 385-396.
Irritable bowel syndrome (IBS) is a functional disorder of the lower gastrointestinal (GI) tract affected by stress, which may benefit from a biopsychosocial treatment approach such as mindfulness-based stress reduction (MBSR).

Don’t forget the Miralax. And when you gotta go…you gotta go.

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