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pWith schizophrenia who are non-responsive to or intolerant of antipsychotic medicationor with psychosis in Parkinson’s disease when other treatment strategies have failedsee section 4.1/ppMyocarditis or cardiomyopathy should be suspected in patients who experience persistent tachycardia at restespecially in the first 2 months of treatmentand/or palpitationsarrhythmiaschest pain and other signs and symptoms of heart failuree.gunexplained fatiguedyspnoeatachypnoeaor symptoms that mimic myocardial infarctionsee section 4.4/ppIf you need surgerytell the surgeon ahead of time that you are using ClozarilYou may need to stop using the medicine for a short time./ppImpaired glucose tolerance and/or development or exacerbation of diabetes mellitus has been reported rarely during treatment with clozapineA mechanism for this possible association has not yet been determinedCases of severe hyperglycaemia with ketoacidosis or hyperosmolar coma have been reported very rarely in patients with no prior history of hyperglycaemiasome of which have been fatalWhen follow-up data were availablediscontinuation of clozapine resulted mostly in resolution of the impaired glucose toleranceand reinstitution of clozapine resulted in its reoccurrencePatients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose controlPatients with risk factors for diabetes mellituse.gobesityfamily history of diabeteswho are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatmentPatients who develop symptoms of hyperglycaemia during treatment with atypical antipsychotics should undergo fasting blood glucose testingIn some caseshyperglycaemia has resolved when the atypical antipsychotic was discontinuedhoweversome patients required continuation of antidiabetic treatment despite discontinuation of the suspect drugThe discontinuation of clozapine should be considered in patients where active medical management of their hyperglycaemia has failed./ppIt is generally recommended that Clozaril should not be used in combination with other antipsychoticsWhen Clozaril therapy is to be initiated in a patient undergoing oral antipsychotic therapyit is recommended that the other antipsychotic should first be discontinued by tapering the dosage downwards./p

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