{"id":4036,"date":"2021-07-19T23:10:31","date_gmt":"2021-07-19T23:10:31","guid":{"rendered":"https:\/\/curesz.org\/?page_id=4036"},"modified":"2023-11-15T14:13:26","modified_gmt":"2023-11-15T19:13:26","slug":"removing-barriers-to-clozapine-use","status":"publish","type":"page","link":"https:\/\/curesz.org\/pt_pt\/removing-barriers-to-clozapine-use\/","title":{"rendered":"Removendo Barreiras ao Uso de Clozapina"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1352px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_4 1_4 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:7.68%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-image-element\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\"fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"300\" height=\"298\" title=\"Tiro na cabe\u00e7a de Meyer\" src=\"https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921.jpg\" data-orig-src=\"https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-300x298.jpg\" alt class=\"lazyload img-responsive wp-image-4037\" srcset=\"data:image\/svg+xml,%3Csvg%20xmlns%3D%27http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%27%20width%3D%271088%27%20height%3D%271080%27%20viewBox%3D%270%200%201088%201080%27%3E%3Crect%20width%3D%271088%27%20height%3D%271080%27%20fill-opacity%3D%220%22%2F%3E%3C%2Fsvg%3E\" data-srcset=\"https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-200x198.jpg 200w, https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-400x397.jpg 400w, https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-600x595.jpg 600w, https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-800x794.jpg 800w, https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-scaled.jpg 1088w, https:\/\/curesz.org\/wp-content\/uploads\/2021\/07\/Meyer-headshot-71921-1200x1191.jpg 1200w\" data-sizes=\"auto\" data-orig-sizes=\"(max-width: 1024px) 100vw, (max-width: 640px) 100vw, 400px\" \/><\/span><\/div><div class=\"fusion-text fusion-text-1\"><p><a href=\"https:\/\/curesz.org\/pt_pt\/about\/board\/jonathan-meyer\/\">Jonathan M Meyer<\/a>, MD Professor Cl\u00ednico de Psiquiatria da Universidade da Calif\u00f3rnia, San Diego Consultor de Psicofarmacologia do Departamento de Hospitais Estaduais da Calif\u00f3rnia, Membro do Conselho da CURESZ<\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_4 3_4 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:75%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.56%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.56%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><p><strong>Removendo Barreiras ao Uso de Clozapina<\/strong><\/p>\n<p>A clozapina \u00e9 o \u00fanico medicamento eficaz no tratamento da esquizofrenia resistente ao tratamento, com taxas de resposta \u2265 40%, em compara\u00e7\u00e3o com &lt; 5% para outros antipsic\u00f3ticos.<sup>1<\/sup> Apesar disso, a clozapina \u00e9 significativamente subutilizada, registando-se uma varia\u00e7\u00e3o de at\u00e9 8 vezes nas taxas de utiliza\u00e7\u00e3o de clozapina entre os estados dos Estados Unidos.<sup>2<\/sup> As principais barreiras \u00e0 utiliza\u00e7\u00e3o da clozapina nos Estados Unidos assentam em duas quest\u00f5es: os encargos da monitoriza\u00e7\u00e3o e o receio do m\u00e9dico prescritor.<sup>3<\/sup><\/p>\n<p>Estas duas quest\u00f5es est\u00e3o interligadas e dizem respeito \u00e0 associa\u00e7\u00e3o entre o uso da clozapina e redu\u00e7\u00f5es significativas nas c\u00e9lulas respons\u00e1veis pela defesa contra infe\u00e7\u00f5es (ou seja, os neutr\u00f3filos) em 1% de doentes. A aprova\u00e7\u00e3o da clozapina nos EUA (1989) veio acompanhada de um acompanhamento obrigat\u00f3rio para monitorizar as contagens de neutr\u00f3filos (gl\u00f3bulos brancos): semanalmente durante 6 meses, de duas em duas semanas durante os 6 meses seguintes e, posteriormente, mensalmente. Embora este acompanhamento tenha praticamente eliminado as mortes relacionadas com infe\u00e7\u00f5es decorrentes da neutropenia induzida pela clozapina (uma contagem baixa de gl\u00f3bulos brancos), o receio suscitado por este e outros efeitos adversos invulgares dissuade muitos m\u00e9dicos de utilizar a clozapina ou de aprender a utiliz\u00e1-la. Embora os dados indiquem que o uso da clozapina reduz a mortalidade,<sup>4<\/sup> muitos cl\u00ednicos sobreestimam os riscos do tratamento e, infelizmente, submetem os doentes a m\u00faltiplas tentativas com outros agentes com poucas hip\u00f3teses de benef\u00edcio terap\u00eautico. A monitoriza\u00e7\u00e3o obrigat\u00f3ria melhorou drasticamente a seguran\u00e7a, mas coloca uma s\u00e9rie de dificuldades aos doentes: custos de desloca\u00e7\u00e3o, tempo, poss\u00edvel necessidade de assist\u00eancia para viajar, desconforto da recolha de sangue, preocupa\u00e7\u00f5es por parte de alguns quanto \u00e0 utiliza\u00e7\u00e3o da sua amostra e o impacto dos atrasos na rece\u00e7\u00e3o da receita seguinte. A dispensa de clozapina est\u00e1 estritamente ligada \u00e0 notifica\u00e7\u00e3o dos resultados sangu\u00edneos \u00e0 farm\u00e1cia, e a quantidade dispensada corresponde ao intervalo at\u00e9 \u00e0 an\u00e1lise de sangue seguinte. Para aqueles que realizam an\u00e1lises semanais, um atraso de 24 horas na desloca\u00e7\u00e3o ao laborat\u00f3rio ou na transmiss\u00e3o dos resultados laboratoriais coloca o doente em risco de ficar sem clozapina.<\/p>\n<p>Ainda assim, h\u00e1 esperan\u00e7a. No sistema hospitalar p\u00fablico com o qual colaboro, um ciclo regular de palestras sobre a clozapina duplicou amplamente a sua prescri\u00e7\u00e3o. Al\u00e9m disso, os sistemas de sa\u00fade em Nova Iorque e nos Pa\u00edses Baixos demonstraram que apoiar os prescritores facilita um maior uso da clozapina. O conhecimento \u00e9, de facto, poder, e os cl\u00ednicos nos Estados Unidos disp\u00f5em de dois novos recursos para facilitar a prescri\u00e7\u00e3o de clozapina. Um deles \u00e9 um manual que co-escrevi, inspirado pela falta de recursos publicados de orienta\u00e7\u00e3o cl\u00ednica sobre a clozapina;<sup>1<\/sup>\u00a0o outro \u00e9 um site educacional baseado na web que (importantemente) tamb\u00e9m fornece consultas cl\u00ednicas para usu\u00e1rios registrados (<a href=\"https:\/\/smiadviser.org\/\">https:\/\/smiadviser.org<\/a>). Esta iniciativa \u00e9 gratuita e \u00e9 patrocinada pela American Psychiatric Association e pela Substance Abuse and Mental Health Services Administration.<\/p>\n<p>Para os pacientes, a carga de monitoramento pode ser reduzida por um dispositivo de ponto de atendimento (POC) rec\u00e9m-aprovado que usa uma pequena gota de sangue de uma picada no dedo. O primeiro desses dispositivos (<a href=\"http:\/\/athelas.com\/\">http:\/\/athelas.com<\/a>) n\u00e3o s\u00f3 fornece resultados em minutos, como os resultados s\u00e3o transmitidos automaticamente para o sistema de monitoriza\u00e7\u00e3o, e o dispositivo tem agora aprova\u00e7\u00e3o da FDA para uso dom\u00e9stico. O desconforto \u00e9 menor, n\u00e3o existe risco de atraso entre a obten\u00e7\u00e3o dos resultados e a dispensa\u00e7\u00e3o da medica\u00e7\u00e3o, e o doente v\u00ea exatamente como a sua amostra de sangue \u00e9 utilizada. A aus\u00eancia de atraso significa que o doente pode realizar o teste a qualquer momento e em praticamente qualquer local com pessoal treinado.<\/p>\n<p>O renascimento da clozapina come\u00e7ou.<\/p>\n<p>Refer\u00eancias:<br \/>\n1. Meyer JM, Stahl SM. Manual da Clozapina. Nova York, NY: Cambridge University Press; 2019.<br \/>\n2. Stroup TS, Gerhard T, Crystal S, Huang C, Olfson M. Varia\u00e7\u00e3o geogr\u00e1fica e cl\u00ednica no uso de clozapina nos Estados Unidos. Psychiatr Serv 2014;65:186-92.<br \/>\n3. Cohen D. Os prescritores temem como um dos principais efeitos colaterais da clozapina. Acta Psychiatr Scand 2014;130:154-5.<br \/>\n4. Vermeulen JM, van Rooijen G, van de Kerkhof MPJ, Sutterland AL, Correll CU, de Haan L. Clozapina e risco de mortalidade a longo prazo em pacientes com esquizofrenia: uma revis\u00e3o sistem\u00e1tica e metan\u00e1lise de estudos com dura\u00e7\u00e3o de 1,1 a 12,5 anos . Boletim de Esquizofrenia 2019;45:315-29.<\/p>\n<h2><\/h2>\n<\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-bottom:0px;--awb-padding-left:0px;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-background-color:#015da7;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><\/div><\/div>\n<\/p>","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-4036","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - 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