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Routine Metabolic Screening Is Necessary for Antipsychotic Treatment: Presented at APA

By Kristina R. Anderson

SAN DIEGO, CA -- May 24, 2007 -- Although antipsychotic treatment guidelines recommend routine metabolic screening, glucose and lipid profiles are not routinely being ordered at baseline by prescribing physicians in a patient population already at risk for diabetes and cardiovascular disease.

That's according to a team of investigators who presented their findings here at the 160^th annual meeting of the American Psychiatric Association (APA).

"These patients who are already at high risk for metabolic disorders need baseline labs and then a follow-up at 12 weeks," said Elaine Morrato, DrPH, University of Colorado at Denver and Health Sciences Center, Colorado, United States. She said that Canada recognizes the schizophrenic population as a high risk for diabetes although the United States does not.

The APA and the American Diabetes Association (ADA) recommend routine metabolic screening, the study points out, and consideration of patient metabolic status when choosing a second-generation or atypical antipsychotic. Atypical antipsychotics have been associated with an increased risk of lipid dysregulation and weight gain.

The study evaluated the association between serum glucose, lipid levels, and atypical antipsychotic treatment choices at three prescribing points:

· Initiation of treatment
· Time of determination to change treatment
· Selection of the switch agent

The purpose of the study was to evaluate the impact of abnormal laboratory test results on the selection of atypical antipsychotic treatment for patients whose lipids and fasting blood glucose (FBG) were being measured.

The study population consisted of both sexes over the age of 18 who were newly being prescribed a single atypical antipsychotic agent. Drugs included in the study were aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone. Certain patient exclusions existed.

Lipid and FBG values were then collected at baseline and pre-switch of medication at three months out. Abnormal values were defined using the Third Report of the National Cholesterol Education Program (NCEP III) and ADA guidelines. Out-of-range values were total cholesterol over 200 mg/dL; triglycerides greater than 200 mg/dL, and FBG more than 126 mg/dL.

The authors' statistical analysis showed the likelihood of abnormal lipid and glucose lab values being "associated with drug selection and switching decisions was assessed using multivariate logistic regression models adjusted for patient age, sex, schizophrenia diagnosis, bipolar disorder diagnosis and pre-existing diabetes and dyslipidemia." All analyses were performed using STATA Version 8.2.

Of the 7,904 adults who were initiated on atypical antipsychotic drug therapy, only 989 (12.5%) actually had glucose, lipid, and triglyceride lab results at baseline and only 699 of 7,904 patients (8.8%) had undergone testing during the follow-up switching period.

Conclusions of the study were as follows:

· Baseline and follow-up metabolic testing is infrequent among adults initiating atypical antipsychotic therapy.

· Little evidence existed that physicians were selecting atypical antipsychotics with lower metabolic risk for patients with elevated metabolic parameters. The sole exception, the authors noted, was that patients with FBG indicative of diabetes were more likely to be started on an atypical antipsychotic with lower metabolic risk.

· Abnormal metabolic results did not increase the likelihood of switching atypical antipsychotics.

· Among patients who were switched to another atypical antipsychotic, those with elevated triglycerides and total cholesterol were more likely to receive ziprasidone, which is consistent with ADA/APA guidelines.

· There is significant opportunity to expand routine metabolic screening and to educate physicians on atypical antipsychotic treatment recommendations for patients with an increased metabolic risk.

Dr. Morrato noted weight gain is obviously a very visible problem. "That's what you can see and these patients are already at risk for cardiovascular disease and diabetes." She suggested that by more closely monitoring patients, they could additionally be treated with statin drugs, for instance. She also emphasized that exercise and diet programs were useful. "Diet and exercise is critical for treatment programs for serious mental illness," she pointed out.

The study was supported by funding from Pfizer Inc.


[Presentation title: Effect of Metabolic Risk Status on Atypical Antipsychotic Treatment Choice. Abstract NR802]

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