Continuation of Clozapine After Priapism

Mr. A was a 25-year-old Hispanic man who suffered from unrelenting paranoia, hallucinations, and negative symptoms. Trials of traditional neuroleptics, risperidone, and olanzapine were attempted. Risperidone was discontinued after one episode of priapism and poor response to treatment. Olanzapine was only minimally effective. When he was taking clozapine, 400 mg/day, Mr. A showed remarkable improvement and was able to seek and maintain employment.

Ten months into treatment, Mr. A had a painful, prolonged erection that lasted 33 hours. Nonsurgical methods were unsuccessful in relieving his discomfort. Placement of a cavernosal glandular shunt was required for detumescence. After Mr. A had recovered, various antipsychotic treatment options were offered to him. Both he and his family felt that the benefits of clozapine outweighed the risk of priapism. Given the refractory nature of his illness as well as the severity of his symptoms at decompensation, he continued to take clozapine at one-half the original dose. Except for one episode of noncompliance and subsequent decompensation, Mr. A has continued to do well and has had only residual negative symptoms. The previous episode of priapism resolved, and Mr. A has reported no recurrence of priapism in over a year.