Clozapine plasma levels may be helpful in improving response rates and minimizing unnecessary side
effects.
Clozapine metabolism:
• Clozapine is subject to considerable metabolism by the cytochrome P450 (CYP) enzyme
system. There are numerous variants of the genes encoding the CYP enzyme family within the
general population, resulting in complex individual genetic profiles and a variable response to
drugs metabolized by these enzymes.
• Clozapine is metabolized to desmethylclozapine by the CYP1A2 (also referred to as
norclozapine) and other compounds, but clozapine is the active CNS drug. Both CYP1A2 ultra-
rapid metabolizers tend to have low clozapine levels at high doses.
One of the most important interactions with clozapine is tobacco smoking, which tends to decrease
clozapine levels by inducing CYP1A2. The induction is by compounds in smoke and not by nicotine so
nicotine replacement medications do not affect clozapine levels. Patients whose clozapine dose was
optimized during a smoke-free inpatient admission will have lower clozapine levels if they resume
smoking as outpatients. Alternatively, stopping smoking is to be encouraged by all patients who smoke.
With successful smoking cessation, clozapine blood levels may increase necessitating gradual
clozapine dose decreases.