CHICAGO – Monitoring patients on second-generation antipsychotic medications for metabolic adverse effects continues to be a clinical challenge, nearly a decade after monitoring recommendations came out.
"After that, if you talked to psychiatrists, almost everyone was aware of the issue and the need to monitor, but the monitoring unfortunately has not caught up," Dr. Rajiv Tandon said at Psychiatry Update 2013.
The consequences are high for patients on second-generation antipsychotics, with metabolic disorders such as diabetes, hypertension, and hyperlipidemia collectively exceeding 50% in some studies of patients with schizophrenia. Moreover, antipsychotic use and diabetes are both rising among Americans. Yet, in the landmark CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study, rates of nontreatment ranged from 30% for diabetes to 62.4% for hypertension and 88% for dyslipidemia (Schizophr. Res. 2006;86:15-22).
Barriers to monitoring for psychiatrists include a lack of time, not knowing what to do with the information when their patient lacks a primary care provider, and patient compliance/reimbursement issues, said Dr. Tandon, of the North Florida/South Georgia Veterans Health System in Gainesville, Fla.
Given that monitoring is such a difficult task for most psychiatrists to take on and do confidently, he suggests they devote the time and effort to cultivating relationships with primary care providers.
"At the VA [Veterans Affairs department] where I work, the place where I’m spending most of my effort with regard to this problem is actually with primary care, trying to help them understand how serious this issue is and why we have to work together in order to help our patients," said Dr. Tandon, who also is a professor of psychiatry at the University of Florida in Gainesville.
"I’ve not been particularly successful thus far; all I’ve been able to accomplish is to get them to listen. It takes time, but it’s well worth it."
The good news is that the Department of Veterans Affairs is spending $60 million annually on metabolic monitoring of veterans on second-generation antipsychotics. The bad news is that anecdotally, metabolic outcomes are only modestly better, Dr. Tandon acknowledged.
Still, he recommends that psychiatrists monitor all their patients on antipsychotics at the start of treatment, at 90 days, and annually thereafter. Monitoring frequency might need to be stepped up in higher-risk patients, such as those with insulin resistance.
Providers also should start patients on an antipsychotic least likely to cause metabolic complications, avoid polypharmacy, and consider adjunctive treatments like metformin in some patients and also lifestyle interventions in combination with patient education.
In a study of 128 adults with first-episode schizophrenia who gained more than 10% of their weight on antipsychotics, 12 weeks of metformin 750 mg/day and lifestyle intervention was superior to either intervention alone, decreasing body mass index on average by 1.8 kg/m2, insulin resistance index by 3.6, and waist circumference by 2 cm (JAMA 2008;299:185-93).
In the future, genetic alterations might help unravel the cross talk between schizophrenia and diabetes, and lead to candidates for drug targets. A recent study identified 33 highly significant susceptibility genes linked to both schizophrenia and type 2 diabetes, including 12 related to tumor necrosis factor and 4 to v-akt murine thymoma viral oncogene homolog 1 (AKT1) (BMC Med. Genomics 2013;6 Suppl. 1:S17).
Dr. Tandon disclosed that he is a member of the World Psychiatry Association Pharmacopsychiatry section. The meeting was sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists. Current Psychiatry and this news organization are owned by the same parent company.