{"id":2491,"date":"2019-08-12T17:08:23","date_gmt":"2019-08-12T17:08:23","guid":{"rendered":"https:\/\/curesz.org\/?page_id=2491"},"modified":"2023-08-28T09:09:24","modified_gmt":"2023-08-28T13:09:24","slug":"messamore-clozapine-question-and-answer","status":"publish","type":"page","link":"https:\/\/curesz.org\/pt_pt\/messamore-clozapine-question-and-answer\/","title":{"rendered":"Messamore Clozapina Pergunta e Resposta"},"content":{"rendered":"

PERGUNTAS E RESPOSTAS SOBRE CLOZAPINA
\n(PDF<\/a>)<\/p><\/h1><\/div><\/div><\/div><\/div><\/div>

Retirado do Boletim CURESZ S\u00e9rie Clozapina
\nnas edi\u00e7\u00f5es 1-4 pelo Dr. Erik Messamore<\/div><\/h1><\/div><\/div><\/div><\/div><\/div>
<\/span><\/div><\/div><\/div>

Erik Messamore<\/a> \u00e9 psiquiatra e professor associado de psiquiatria na Northeast Ohio Medical University. Ele atua como diretor m\u00e9dico do Centro de Melhores Pr\u00e1ticas em Tratamento de Esquizofrenia (BeST) da Universidade. Ele possui um MD e um PhD em farmacologia. O Dr. Messamore tamb\u00e9m atuou no Conselho de Curadores da Funda\u00e7\u00e3o CURESZ.<\/p>\n<\/div><\/div><\/div><\/div><\/div>

PARTE UM DE QUATRO<\/h1><\/div>

P: Parte do seu trabalho envolve ajudar os m\u00e9dicos a usar a clozapina. O que o torna t\u00e3o interessado nesta causa?<\/h1><\/div>

A clozapina salva vidas e melhora a qualidade de vida de uma forma que outros medicamentos simplesmente n\u00e3o conseguem. A clozapina \u00e9 o melhor medicamento para cerca de 20% de pessoas com esquizofrenia, mas nos Estados Unidos \u00e9 usada em apenas 4%. Isso significa que cerca de 16% de pessoas com esquizofrenia (quase meio milh\u00e3o de indiv\u00edduos) n\u00e3o t\u00eam a qualidade de vida que pode ser obtida com esse medicamento incompar\u00e1vel. Certa vez, trabalhei em um hospital estadual e me tornei o m\u00e9dico de uma senhora com esquizofrenia. Vamos cham\u00e1-la de "Anna". Ela esteve continuamente doente por cerca de 20 anos, saltando entre o hospital, a rua e, \u00e0s vezes, a pris\u00e3o. Como uma sem-teto com doen\u00e7a mental grave, ela experimentou uma s\u00e9rie de traumas realmente horr\u00edveis. Anna nunca havia experimentado clozapina porque: 1) os m\u00e9dicos presumiram que ela n\u00e3o tomaria o medicamento regularmente ou que seu \u201cestilo de vida\u201d era muito ca\u00f3tico para poder comparecer aos exames de sangue semanais; e 2) ela tinha muito medo de agulhas, ent\u00e3o recusaria a oferta de clozapina de qualquer maneira.<\/p>\n

To address her fear of needles, I prescribed an anesthetic cream that we would rub into the spot where we were would draw blood. The anesthetic cream numbed the skin and helped Anna feel comfortable with blood testing so she agreed to try clozapine.<\/p>\n

Em dois meses, vimos a verdadeira Anna. Ela era uma senhora encantadora com senso de humor. Ela p\u00f4de, pela primeira vez desde que adoeceu, participar ativamente de seu planejamento de alta.<\/p>\n

Ela tomava a medica\u00e7\u00e3o regularmente porque sentia que realmente a ajudava. (A raz\u00e3o pela qual ela parou de tomar os medicamentos anteriores \u00e9 porque eles n\u00e3o estavam realmente ajudando de uma maneira que importava para ela.) Ela conseguiu seu pr\u00f3prio apartamento e come\u00e7ou a criar o tipo de vida que desejava. A clozapina a ajudou a quebrar o ciclo de doen\u00e7a e falta de moradia e permitiu que Anna recuperasse uma vida na qual ela estava no comando.<\/p>\n

Por v\u00e1rias raz\u00f5es, muitos m\u00e9dicos nos Estados Unidos n\u00e3o oferecem clozapina a seus pacientes com esquizofrenia. Parte do meu trabalho hoje em dia \u00e9 ajudar m\u00e9dicos ou enfermeiras psiqui\u00e1tricas a usar clozapina para que possam ver por si mesmos que hist\u00f3rias de sucesso como a de Anna s\u00e3o realmente muito comuns com esse medicamento excepcionalmente eficaz.<\/p>\n<\/div><\/div><\/div><\/div><\/div>

PARTE DOIS DE QUATRO<\/h1><\/div>

P: A clozapina \u00e0s vezes \u00e9 chamada de \u201cdroga maravilhosa\u201d. Voc\u00ea concorda com isso?<\/h1><\/div>

I’m not a fan of labels like “wonder drug” for medications. The most successful outcomes are usually the result of treatment that combines multiple approaches like psychotherapy, environmental modification, bolstering social support, and helping people to reconnect to the things in life that give them meaning, purpose, and joy. Labeling a particular medication \u201cmiraculous\u201d creates a risk of over-focusing on one approach even when others are also valuable. On the other hand, clozapine does appear to have a higher level of treatment effectiveness than any other medication for schizophrenia and can be uniquely effective in cases where other medications have failed. The average patient will have spent several years dealing with inadequately effective medications before she or he is offered clozapine. To someone who has struggled with symptoms for so long, finally being on a truly effective medication certainly can feel miraculous.<\/p>\n<\/div>

P: Por que alguns m\u00e9dicos e enfermeiros psiqui\u00e1tricos n\u00e3o t\u00eam muita experi\u00eancia na prescri\u00e7\u00e3o de clozapina?<\/h1><\/div>

Formas gen\u00e9ricas de clozapina tornaram-se dispon\u00edveis no final da d\u00e9cada de 1990. Quando um medicamento se torna dispon\u00edvel como gen\u00e9rico, ele n\u00e3o \u00e9 mais divulgado ativamente por uma empresa farmac\u00eautica. N\u00e3o h\u00e1 mais publicidade em jornais profissionais, n\u00e3o h\u00e1 promo\u00e7\u00e3o em confer\u00eancias, ningu\u00e9m vem ao seu escrit\u00f3rio para ajudar a responder a perguntas. Na mesma \u00e9poca, v\u00e1rios outros novos medicamentos de \u201csegunda gera\u00e7\u00e3o\u201d ou \u201cat\u00edpicos\u201d estavam chegando ao mercado, e esses medicamentos mais novos foram amplamente promovidos por seus fabricantes. A promo\u00e7\u00e3o corporativa da clozapina desapareceu enquanto a publicidade de drogas mais novas e menos eficazes floresceu. Voc\u00ea pensaria que as escolas de medicina e os programas que treinam psiquiatras compensariam. Mas isso n\u00e3o aconteceu de forma generalizada. A organiza\u00e7\u00e3o nacional que dita o curr\u00edculo de treinamento para os programas de resid\u00eancia do pa\u00eds n\u00e3o aborda especificamente o ensino da clozapina. Se um determinado programa de treinamento oferece treinamento espec\u00edfico para clozapina, depende do programa individual. N\u00e3o \u00e9 um padr\u00e3o nacional. Portanto, \u00e9 inteiramente poss\u00edvel para um novo psiquiatra iniciar a pr\u00e1tica sem nenhuma experi\u00eancia em primeira m\u00e3o para prescrever clozapina e observar seus benef\u00edcios not\u00e1veis. Ausente dessa experi\u00eancia, um psiquiatra rec\u00e9m-formado pode iniciar a pr\u00e1tica despreparado para usar esse medicamento. A situa\u00e7\u00e3o \u00e9 a mesma para os enfermeiros psiqui\u00e1tricos. Essas lacunas no treinamento criaram o que chamo de uma gera\u00e7\u00e3o perdida de m\u00e9dicos que hesitam em usar a clozapina.<\/p>\n<\/div><\/div><\/div><\/div><\/div>

PARTE TR\u00caS DE QUATRO<\/h1><\/div>

P: O que voc\u00ea acha que torna a clozapina eficaz em situa\u00e7\u00f5es em que outros medicamentos n\u00e3o foram?<\/h1><\/div>

Not all schizophrenias are alike. Understanding that there are different kinds of schizophrenia helps to explain why clozapine appears uniquely effective. Most schizophrenias should probably be renamed “dopamine psychosis”. Scientists have shown that many people with schizophrenia have unusually high dopamine signals in key brain circuits. These findings explain why antipsychotic medications are effective. Most all of them are designed to adjust the elevated dopamine signals.<\/p>\n

About two thirds of people with schizophrenia will have one of these high-dopamine forms of illness and will find relief from dopamine-adjusting medications. But there are other forms of schizophrenia where the dopamine signal appears entirely normal. A variety of neurochemical studies, including some recent PET scan work, has shown that people with these normal-dopamine schizophrenias don’t get much symptom relief from the first-line, dopamine-adjusting schizophrenia medications. This makes sense. Why would we expect that dopamine-focused medications would benefit someone without a high-dopamine brain? “Treatment-resistant schizophrenia” is the name that the field has sort of settled on to refer to the forms of schizophrenia that don’t respond to non-clozapine medications. This label is unfortunate, in my opinion, because it is both discouraging and misleading. The majority of so-called treatment-resistant cases actually respond beautifully to clozapine. It’s not that these illnesses were resistant to treatment. It’s that these folks have a normal-dopamine form of schizophrenia that won’t be served by dopamine-adjusting meds. Clozapine works in the majority of these schizophrenias because clozapine is not a dopamine-adjusting medication. Clozapine is the only thing we know of that works well for normal-dopamine schizophrenia.<\/p>\n<\/div>

P: Como algu\u00e9m sabe se tem uma forma de esquizofrenia com dopamina alta ou com dopamina normal?<\/h1><\/div>

\u00c9 poss\u00edvel medir a sinaliza\u00e7\u00e3o de dopamina em humanos, mas as t\u00e9cnicas n\u00e3o est\u00e3o dispon\u00edveis fora de estudos de pesquisa. Por outro lado, os padr\u00f5es de resposta \u00e0 medica\u00e7\u00e3o podem ser guias \u00fateis. Se os sintomas responderem aos medicamentos de ajuste do sinal de dopamina, \u00e9 bem prov\u00e1vel que a psicose seja do tipo alta dopamina. Por outro lado, se os sintomas n\u00e3o melhoraram muito apesar dos medicamentos de ajuste de sinal de dopamina dosados adequadamente, \u00e9 prov\u00e1vel que haja uma psicose de dopamina normal. Prestar aten\u00e7\u00e3o \u00e0 resposta \u00e0 medica\u00e7\u00e3o \u00e9 um m\u00e9todo indireto de descobrir se algu\u00e9m tem uma esquizofrenia de alta dopamina ou uma esquizofrenia de dopamina normal.<\/p>\n<\/div><\/div><\/div><\/div><\/div>

PARTE QUATRO DE QUATRO<\/h1><\/div>

P: Que efeitos colaterais graves voc\u00ea observou em pacientes que tomam clozapina?<\/h1><\/div>

A maioria das pessoas teme a possibilidade de suprimir a contagem de gl\u00f3bulos brancos com a clozapina. Como os gl\u00f3bulos brancos s\u00e3o a primeira linha de defesa contra infec\u00e7\u00f5es, uma redu\u00e7\u00e3o dr\u00e1stica em seu n\u00famero pode levar a infec\u00e7\u00f5es muito graves. Embora ter pequenas quedas na contagem de gl\u00f3bulos brancos seja relativamente comum, a maioria \u00e9 tempor\u00e1ria e insignificante. Ter uma supress\u00e3o de gl\u00f3bulos brancos clinicamente grave da clozapina \u00e9 realmente rara (menos de 1%). Obter uma infec\u00e7\u00e3o de tal supress\u00e3o \u00e9 ainda mais raro porque a contagem de gl\u00f3bulos brancos \u00e9 medida com frequ\u00eancia. A complica\u00e7\u00e3o medicamente grave mais comum da clozapina est\u00e1 relacionada \u00e0 constipa\u00e7\u00e3o. Em suas formas mais graves, a constipa\u00e7\u00e3o pode levar a uma emerg\u00eancia m\u00e9dica. \u00c9 importante prestar aten\u00e7\u00e3o \u00e0 frequ\u00eancia das evacua\u00e7\u00f5es e tomar medicamentos, se necess\u00e1rio, para garantir movimentos intestinais regulares. Trabalhei como psiquiatra consultor durante a maior parte da minha carreira. Os pacientes que atendo se beneficiaram apenas parcialmente de muitas tentativas anteriores de tratamento. Provavelmente j\u00e1 vi todos os efeitos colaterais poss\u00edveis da clozapina durante minha carreira, mas isso porque trabalhei principalmente com pacientes com as formas mais complexas de doen\u00e7a. Muitos dos efeitos colaterais da clozapina podem ser evitados n\u00e3o usando altas doses e tomando cuidado para n\u00e3o prescrever medicamentos que n\u00e3o ser\u00e3o necess\u00e1rios quando a clozapina atingir n\u00edveis terap\u00eauticos. O ganho de peso \u00e9 um risco com a clozapina, mas pode ser minimizado ou evitado por dieta e exerc\u00edcios, possivelmente combinados com medicamentos como metformina ou liraglutida que promovem a perda de peso. Existem solu\u00e7\u00f5es semelhantes para v\u00e1rios outros poss\u00edveis efeitos colaterais da clozapina. Saber o que procurar permite a detec\u00e7\u00e3o precoce de efeitos colaterais potencialmente graves e a interven\u00e7\u00e3o precoce para evitar danos.<\/p>\n<\/div>

P: Qual \u00e9 a coisa mais importante que voc\u00ea compartilha com os m\u00e9dicos que est\u00e3o aprendendo a usar a clozapina?<\/h1><\/div>

Don’t delay. The research is clear: the longer someone experiences psychosis, the lower their prospects for long-term recovery. So, getting someone into remission as soon as possible is one of the most important goals in the care of individuals suffering from acute psychosis. Patients with recent-onset schizophrenia should go into remission (or be well on their way to remission) within no more than 8 months of treatment with antipsychotic medication (up to four months with medication #1, and up to four months with medication #2 if medication #1 failed to work). If delusions or hallucinations are not controlled by two different antipsychotic medications, the likelihood that the patient will respond to a third medication is minuscule, unless that medication is clozapine \u2013 where the response rate is more than 50%. Delaying the initiation of clozapine is equivalent to prolonging the duration of psychosis. And prolonged duration of psychosis has been shown to reduce quality of life in both the short-term and long-term.<\/p>\n<\/div>

P: Que conselho voc\u00ea gostaria de oferecer a outros m\u00e9dicos que prescrevem clozapina?<\/h1><\/div>

Muitas pessoas odeiam tirar sangue com frequ\u00eancia e podem se recusar a considerar a clozapina por causa disso. O creme anest\u00e9sico t\u00f3pico, para anestesiar a pele no local da coleta de sangue, pode ser realmente \u00fatil para algu\u00e9m que pode n\u00e3o considerar a clozapina devido aos requisitos de teste de gl\u00f3bulos brancos.<\/p>\n<\/div><\/div><\/div><\/div><\/div>

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