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Subjects/Psychiatry/Antipsychotics
Antipsychotics
hard
brain Psychiatry

A 28-year-old patient with chronic schizophrenia has failed trials of two different antipsychotics, including one atypical, each for an adequate duration and dose. The psychiatrist is considering initiating clozapine. Which of the following is an absolute prerequisite before starting clozapine therapy?

A. A. Baseline ECG to rule out QTc prolongation.
B. B. Baseline complete blood count (CBC) to monitor for agranulocytosis.
C. C. Liver function tests to assess for hepatotoxicity.
D. D. Serum prolactin levels to monitor for hyperprolactinemia.

Explanation

Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia. Its most serious and potentially fatal side effect is agranulocytosis, which necessitates mandatory weekly complete blood count (CBC) monitoring for the first 6 months, then bi-weekly, and eventually monthly, as per national guidelines (e.g., REMS program in the US). While ECG (A) is important due to cardiac risks (myocarditis, QTc prolongation), LFTs (C) for hepatotoxicity, and prolactin levels (D) for hyperprolactinemia are also relevant considerations for antipsychotic use, none are an *absolute prerequisite* for initiation with the same strictness and regulatory requirement as baseline CBC for agranulocytosis monitoring with clozapine.

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