Clozapine treatment in chronic lymphocytic leukaemia and pancytopenia

There is a paucity of literature regarding clozapine initiation in patients with haematologic malignancies. We present the case of a patient with chronic lymphocytic leukaemia (CLL) and schizoaffective disorder whose clozapine was discontinued and restarted. A woman in her 60s presented to the emergency department with hypotension and symptomatic pancytopenia. Clozapine was discontinued due to the risk of neutropenia during her admission to the haematology service. Bone marrow aspiration revealed that the pancytopenia was due to CLL clonal invasion, and the decision was made to restart clozapine. The subsequent development of hospital-acquired pneumonia led to clozapine discontinuation. An evaluation of the harms and benefits of clozapine re-initiation is discussed considering the possible additive effects of clozapine and CLL on degrading immune function, the risk of opportunistic infections, and the cytotoxic effects of CLL treatment. In medicated patients with stable psychopathology the reintroduction of clozapine after completion of CCL treatment can help minimise the risk of physical complications. Earlier reintroduction of clozapine may be justified in symptomatic patients with close monitoring. Informed decisions should be guided by patients’ preferences after judicious evaluation of risks and benefits. Haematology-psychiatry collaboration is essential to best manage cases with complex, comorbid psychiatric and haematological conditions.