“When was your last bowel movement?” A Case Study on Treatment Resistant Constipation in a Patient on Clozapine

This work was sponsored by University of California San Francisco Constipation and gastrointestinal hypomotility are common side effects that must be properly managed when a patient is on clozapine therapy. Failure to prescribe a through bowel regimen for patients on this medication can not only be uncomfortable, it can be fatal. The following case study will provide an example of a comprehensive bowel regimen that was shown to be effective in the resolution of constipation for this patient. DH has a history of treatment refractory schizophrenia dating back to the late 1990’s and as a result has been treated with clozapine since 1999. Unfortunately he’s had breaks in his medication adherence, usually coinciding with a return to alcohol use, and his baseline functioning has declined over the years. DH was re-started on clozapine during his most recent acute hospitalization and has been consistently taking it for about 10 months. His symptoms are in partial remission but unfortunately he has experienced side effects of weight gain, metabolic syndrome, akathisia and more recently treatment resistant constipation and drooling. Magnesium preparations such as magnesium citrate can only be used once per week or less due to risk of hypermagnesemia, secretagogues such as lubiprostone are a good option for treatment resistant constipation (Meyer & Stahl, 2021). Lubiprostone is a prostaglandin E1 analogue which stimulates Cl channels on GI epithelial cells, ultimately softening stool and promoting motility (Meyer & Stahl, 2021). We decided to start lubiprostone and within the following week his bowel movements returned to every other day.