Restarting Clozapine Treatment During Ablation Chemotherapy and Stem Cell Transplant for Hodgkin’s Lymphoma

“Mr. S” was a 39-year-old white male with a history of bipolar I disorder who presented on a responsive regimen of clozapine (300 mg b.i.d.) and lithium (1800 mg every night), with the occasional addition of benzodiazepines, for 10 years. In February 2006, he was admitted with an exacerbation of his mania, characterized by pressured speech, expansive affect, decreased sleep, and psychomotor agitation. He reported weight loss with episodes of night sweats, pruritic rash, and painless lymph node swelling. Oncology diagnosed the patient with Hodgkin’s lymphoma, nodular sclerosing type. Clozapine was discontinued because of the concern of clozapine-induced agranulocytosis, and the patient was switched to a regimen of olanzapine (30 mg b.i.d.). Lithium and lorazepam were continued.

Subsequently, in July 2006 the patient presented with a decompensation of his bipolar disease, despite treatment with olanzapine. Because of his poor response to olanzapine, we considered restarting clozapine, even in the context of active Hodgkin’s lymphoma.

The patient was scheduled to receive ablation chemotherapy and a stem cell transplant during that hospitalization. Concerned about the possibility of leukopenia from Hodgkin’s disease treatment, we contacted IVAX pharmaceuticals to determine whether the patient would be eligible for a waiver, because generally clozapine must be immediately discontinued if a patient develops leukopenia (white blood cell count <3000 cell/mm ³ with a satisfactory neutrophil count) or neutropenia (neutrophil count <1500 cell/mm ³ ). It was decided that the benefits outweighed the risks. The waiver was granted and clozapine was restarted.

In August 2006 the patient was transferred to another hospital to receive his stem cell transplant. During that treatment, his white blood cell count was 0.1 cell/mm ³ with ANC <0.02. Postprocedure, his white blood cell count was 9.9 cell/mm ³ . He returned to our inpatient unit in September 2006. His white blood cell count since then has remained between 5.5 and 9.9 cell/mm ³ .