His mental state showed marked either improvement on clozapine. He was

discharged from hospital on clozapine 300 mg After starting clozapine he developed hypersalivation and bilateral painful parotid gland swellings; he was initially treated with hyoscine hydrobromide, which resulted in urinary retention. Hence he was given tamsulosin to treat the urinary retention. This these strategy resulted in a partial improvement of hypersalivation and some improvement of urinary retention, but little improvement in the swelling and pain, and unfortunately he developed a sexual side effect of retrograde ejaculation. Mr G was extensively investigated Inhibitors,research,lifescience,medical for any parotid pathology with blood tests for infection and inflammatory markers, a computerized tomography scan, magnetic resonance imaging and sialogram, which ruled out all the common conditions such as salivary stones Inhibitors,research,lifescience,medical or infections. The reports noted bilateral parotid hypertrophy with no localized lesions. Various strategies were tried to relieve the parotid swelling. Initially the clozapine dosage was reduced to 250 mg, while rigorously monitoring his serum clozapine levels. This resulted in some improvement Inhibitors,research,lifescience,medical in parotid side effects, but a worsening of his psychotic symptoms. In an effort to better treat the psychosis he was augmented with amisulpride, but this had little benefit. Hence the clozapine dose was increased back to 300 mg and the amisulpride discontinued, with a relapse of parotid

gland swelling and pain as expected. Options to treat him with another antipsychotic

such as quetiapine were explored Inhibitors,research,lifescience,medical but not tried, as the risk of relapse and consequent increase in risk to others were deemed high. We tried a new strategy after an extensive literature review. Hyoscine hydrobromide and tamsulosin were reduced and stopped; this helped improve urinary and sexual side effects. He was then treated with benzatropine 1 mg initially, titrated up to 2 mg/day over a period of 3 months, resulting in a mild reduction in symptoms. Hence, terazosin was added to this at an initial Inhibitors,research,lifescience,medical dose of 1 mg/day, subsequently increased to 2 mg/day. This resulted in a good effect, as the hypersalivation reduced in intensity with a gradual reduction in the parotid gland swelling. At 3 months into the treatment with this combination of benzatropine and terazosin the parotid gland swelling was completely gone. Mr G has been on clozapine 150 mg twice daily, mirtazapine AV-951 45 mg, benzatropine 2 mg at night, terazosin 2 mg at night, and diazepam 5 mg as required for 2.5 years. During this time he has enjoyed a stable mental health. He now reports little hypersalivation. On occasions of noncompliance with medication, a pain-free left parotid swelling reappears, which resolves quickly with treatment. He also reports an increase in confidence and an improved social life. He has been able to maintain himself in the community, with a care plan involving minimal nursing and medical input.