Continuation of Clozapine Treatment in Lung Transplantation

Abstract:
Background: Current understanding of and experience with the management of patients taking clozapine who need solid organ transplant is sparse (Lim, 2016) with only three case reports in the literature (Harrington, 2008, Padda 2024). Clozapine is an essential antipsychotic for patients with treatment-resistant schizophrenia that cannot be replaced by other psychotics without the risk of psychotic relapse (Ciapparelli, 2003). However, clozapine is associated with many side effects, including neutropenia (Myles, 2018), that may present barriers to transplant candidacy or require psychiatric consultation during organ transplantation.

Methods: We first conducted a literature search for any publications regarding the use of clozapine during transplant. We then conducted a case review using natural language processing of the Partners Research Patient Data Registry to identify individuals over age eighteen who had taken clozapine at any time and been evaluated for or undergone solid organ transplant. We reviewed these cases and summarized clinical findings. We additionally included two case reports of continuing clozapine during solid organ transplant, including the first reported case of continuing clozapine during lung transplantation.

Results: Twelve cases were identified in which the patient had taken clozapine and been evaluated for or undergone solid organ transplant. One case underwent renal transplantation and one case underwent lung transplantation while remaining on clozapine and these case reports are provided.

Discussion: The literature review and retrospective chart review highlight the limited available guidance for providers and patients who may require clozapine treatment and organ transplantation. The case reports highlight several clinical issues that providers should consider when managing clozapine during transplantation, including drug-drug interactions, clozapine withdrawal, and clozapine specific side-effects.

Conclusion: This publication aims to provide consulting psychiatry and transplant providers with an additional resource for managing and continuing clozapine treatment during transplantation. It includes the most recent literature review, the first case report of lung transplantation on clozapine, and a brief summary of recommendations regarding the unique clinical issues that may arise with clozapine treatment in transplant patients. The authors provide a set of guidelines for psychiatrists who may be consulted to assist with management of clozapine in the transplant setting.