Alert for the efficiency of the clozapina, in high doses, in refractory mania to pharmacological treatment.

Review of literature relevant after the description of a clinical case example.

Description of a clinical case: Woman 30 years, ethnicity african, with bipolar disease type 1, with 12 years of evolution, and 11 treatments with around 1 year duration. Specifics took place with medication, such as intolerance to mood stabilizers, including lithium and valproate. Last inpatient care, with 5 months, it was for outbreak manic characterized by huge dysphoria and easy irritability with aggressiveness. There were administered antipsychotics, in high doses, and attempted electroconvulsive therapy, without success. Clinical remission has been achieved by the gradual increase of clozapina, in accordance with the patient tolerance, until 1400 mg daily without occurrence of agranulocytosis. The only intercurrence was a epileptic seizure, controlled with phenytoin.

Refractory mania is treated with clozapina in high doses, which must be administered according to the patient tolerance and clinical improvement. The risk of agranulocytosis (1-3%) is low, and is the only formal indication to suspend the treatment. The extensive metabolizers do not respond to conventional doses of psychotropic substances, they need larger doses and are more frequent in african people.