Clozapine Therapy During Cancer Treatment
Ms. A was a 46-year-old white woman with schizophrenia who had been doing well taking clozapine since 1991 (700 mg/day, blood levels >430 ng/ml). Blood monitoring showed her total leukocyte counts to be generally above 5000/mm3, with absolute neutrophil counts >3000/mm3. Her other medications included perphenazine, citalopram, lorazepam, thyroxine, and oral contraceptives.In September 2001, she was diagnosed with breast cancer and underwent segmental mastectomy. She began a four-cycle course of doxorubicin and cyclophosphamide and continued to take clozapine.As expected, doxorubicin induced significant leukopenia (as low as 1300 leukocytes and 300 neutrophils). After the nadirs, Ms. A’s counts returned to normal. However, after chemotherapy and a 6-week course of radiotherapy, her counts declined again, leveling off with leukocyte counts below 3000 and absolute neutrophil counts below 2000. Her oncologist opined that the leukopenia was not related to radiation. Ms. A’s counts remained low over the next 6 months, and hematologic consultation, including a bone marrow biopsy, yielded no other cause for neutropenia besides clozapine. Ms. A remained free from cancer, infection, and psychoses after her surgery, and she remains well at this time.
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