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Clozapine and Diabetes Management — MRCPsych Paper B MCQ

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HardSchizophrenia & PsychosisClozapine and Diabetes ManagementMRCPsych Paper B

A 31-year-old woman with treatment-resistant schizophrenia has remained well for 2 years on clozapine. Previous treatment with adequate trials of other antipsychotics was ineffective, and interruption of clozapine precipitated a severe relapse. Type 2 diabetes is confirmed, with an HbA1c of 55 mmol/mol. She has normal renal function and no symptoms or biochemical evidence of diabetic ketoacidosis or a hyperosmolar state. What is the most appropriate next management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Continue clozapine alongside structured lifestyle support and guideline-directed glucose-lowering treatment

Explanation lettering: B = shown as A · C = shown as B · A = shown as C

B is correct. Clozapine has been uniquely effective, and uncomplicated diabetes is not in itself an indication to withdraw it. The clozapine SmPC advises considering discontinuation only when active medical management of hyperglycaemia has failed. Diabetes should therefore be treated actively, with lifestyle support and coordination with primary care or diabetes services. Under NICE NG28, diabetes diagnosed before age 40 is early-onset type 2 diabetes: initial treatment should include modified-release metformin and an SGLT-2 inhibitor, with consideration of a GLP-1 receptor agonist or tirzepatide. Switching to aripiprazole risks relapse and is premature. Lifestyle intervention alone inadequately treats confirmed diabetes. Abrupt clozapine cessation risks rapid psychotic recurrence and withdrawal phenomena. Immediate insulin is generally reserved for specific indications such as marked symptomatic hyperglycaemia or failure of appropriate non-insulin treatment, none of which is present.

Reference: Clozaril 100 mg Tablets, Summary of Product Characteristics, section 4.4 (Hyperglycaemia), electronic Medicines Compendium, current version 2026. https://www.medicines.org.uk/emc/product/10290/smpc