Metabolic Monitoring, Schizophrenia Spectrum Illnesses, & Second Generation Antipsychotics Lauren Hanna, M.D. & Delbert Robinson, M.D. The Zucker Hillside Hospital Northwell Health National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies
Objectives • To understand the relationship between • Serious Mental Illness (SMI) • antipsychotic medication • metabolic & cardiovascular risk factors • To understand the importance of • screening for modifiable risk factors for those on antipsychotics • To understand the guidelines for • metabolic monitoring among the SMI populations taking second generation antipsychotics (SGAs)
You Can Save Lives! • People with Schizophrenia die decades earlier due to preventable medical illness • Signs of medical illness are often present early, but medical care is tragically often suboptimal • We can stop this premature death by • Prevention efforts • Monitoring for metabolic problems • Successful referral for treatment if metabolic problems are detected
People with SMI Die Decades Earlier • People with serious mental illness have mortality rates 2 or 3 times as high as the general population • This translates to 13-30 years shorter life expectancy • 60% of this excess mortality is due to physical illness
One Of Multiple Studies Showing That Schizophrenia Is A Deadly Disease • Olfson and colleagues studied 1,138, 853 individuals with schizophrenia in the Medicaid program. Those with schizophrenia were more than 3.5 times as likely to die in the follow-up period compared with adults in the general population. On average, the years of potential life lost for each deceased individual were 28.5 years. Premature Mortality Among Adults With Schizophrenia in the United States JAMA Psychiatry. 2015;72(12):1172-1181.
These Deaths are Preventable • The increased morbidity and mortality is largely seen due to higher prevalence of modifiable risk factors • Of the physical health problems, specifically metabolic and cardiovascular co-morbidity are increasingly important • Of the SMI population, people taking antipsychotic medication often have multiple related cardiovascular and metabolic risk factors
Metabolic and Cardiovascular Risk Factors • Hypertension • Diabetes • Pre-diabetes • Obesity • Waist circumference • Cholesterol • Triglycerides
What is is the prevalence of f obesity, pre-diabetes, and type 2 dia iabetes in in the populations in in whic ich the SGAs are used? • The prevalence of diabetes and obesity among individuals with schizophrenia an affective disorders is thought to be ~1.5-2 x higher than on the general population
Signs of medical illness are often present early, but medical care is usually suboptimal
Even Though First Episode Patients Are Young and Have Had Limited Antipsychotic Treatment, Medical Co- Morbidities Are Common N=394 Mean age =23 years Mean lifetime days of antipsychotic treatment = 47 days Correll et al JAMA Psychiatry 2014
Note How Common Abnormalities Are and How Infrequent Is Treatment N=394 Mean age =23 years Mean lifetime days of antipsychotic treatment = 47 days Correll et al JAMA Psychiatry 2014
Those with Psychiatric Diagnoses Receive Inferior Quality of Care • In a comparative review, more than 70% of studies found that patients with psychiatric diagnoses receive inferior quality of care in at least one medical area (Mitchell et al. 2009)
SGAs & Risk Factors • Most antipsychotic agents are closely linked with adverse effects on weight, lipids, and glucose metabolism, and cardiovascular disease
If Metabolic Abnormalities Are So Prevalent, What Should We Do? • For people without metabolic abnormalities, we want to prevent metabolic abnormalities from occurring • Factor metabolic side effect profiles into your decision process about what antipsychotic to prescribe • Consider metabolic side effect profiles into your decision process about adding other medications such as mood stabilizers • Healthy lifestyle and nutritional education should be provided to all patients
If Metabolic Abnormalities Are So Prevalent, What Should We Do? We have to following monitoring guidelines for doing tests, and we have to make sure that our patients get the tests
Monitoring Catches Modifiable Risk Factors: Inpatient Screening • Routine testing of 733 newly admitted inpatients with schizophrenia found: • 6% with diabetes • 17% with hypertension • 24% with obesity • 27% with hypertryglyceridemia • 66% with high cholesterol (Bernardo et al. 2009) • Modifiable risk factors are also commonly found in outpatients with schizophrenia (Meyer et al . 2005, Arango et al . 2008, De Hert et al. 2008, Shi et al . 2009)
Metabolic Monitoring should occur more frequently for those on SGAs…but often it occurs less frequently • People with SMI on antipsychotics represent a vulnerable group for whom more frequent metabolic monitoring is indicated • The signs present early • Early intervention is possible and appropriate • Despite this, access to and quality of health care is problematic for individuals with SMI
Many Prescribed SGAs Aren’t Screened for Preventable Cardiovascular Risk Factors Monitoring Grades • 39 studies involving 218940 • <50% inadequate patients • >= 50% suboptimal • in the UK, Canada, Spain the USA and Australia • >=70% adequate • examined screening practices on • >=80% good routine clinical care • >=90% optimal • all subgroups (not only psychotics spectrum).
Many Prescribed SGAs aren’t Screened for Preventable Cardiovascular Risk Factors Metabolic Monitoring Rate of Testing Grade Parameter Weight 47.9% Inadequate Blood pressure 69.8% Suboptimal Glucose 44.3% Inadequate Lipid 22.2% Inadequate Cholesterol 41.5% Inadequate Triglyceride 59.9% Suboptimal HbA1c 16.0% Inadequate
Many Prescribed SGAs Aren’t Screened for Preventable Cardiovascular Risk Factors 23.76% = The percentage of patients in NY State with diagnoses of Schizophrenia or Bipolar Disorder prescribed antipsychotics … … but without Hemoglobin A 1c or LDL-C measured in previous 12 months 29.83% = The percentage of patients in NY State with diagnoses of both Schizophrenia and diabetes … … without Hemoglobin A 1c measured in previous 12 months
SGAs Contribute to RISK FACTORS, BUT… …More Metabolic monitoring is needed… …not less SGA Use
Guidelines & Recommendations
• How should patients be monitored for the development of significant weight gain, dyslipidemia, and diabetes, and how should they be treated if diabetes develops?
Consensus Conference 2004 Monitoring Recommendations
If patients have abnormalities on testing, the frequency of testing is modified and individualized: • To the abnormality in questions • Based on the severity of the abnormality • Customization is determined by coordination with patient’s primary medical doctor, patient, and psychiatrist • Customization can include healthy lifestyle strategies, medication strategies or a combination of these
When To Do an Intervention • There are varied professional guidelines and they sometimes differ on particular recommendations • The important point is to choose a guideline and IMPLEMENT the recommendations • As an example, we will present in the following slides some of the recommendations from the Mount Sinai Conference on Physical Health Monitoring of Patients With Schizophrenia (Am J Psychiatry 2004; 161:1334 – 1349)
Obesity, Diabetes, Hyperlipidemia
Obesity 1. Monitor and document the BMI of every patient with schizophrenia, regardless of the antipsychotic medication prescribed a. Weigh patients at every visit and track those weights b. Encourage patients to monitor and chart their own weight c. Measure and document waist circumference d. Patients should be weighed/measured at every visit for the first 6 months after medication initiation or change
Obesity 2. The relative risk of weight gain for the different antipsychotic medications should be a consideration in drug selection for patients who have BMI ≥ 25 3. Unless a patient is underweight (BMI < 18.5), a weight gain of 1 BMI unit indicates a need for an intervention Waist circumference ≥ 35 inches for women or ≥ 40 inches for men also warrants intervention 4. Interventions may include closer monitoring of weight, engagement in a weight management program, use of an adjunctive treatment to reduce weight, or changes in a patient’s antipsychotic medication
Diabetes 1. Mental health care providers should be aware of risk factors for diabetes for all patients with schizophrenia a. Measure baseline plasma glucose level (fasting preferred, but hemoglobin A 1c acceptable) • Fasting glucose between 100mg/dl and 125mg/dl indicate prediabetes and prompt closer assessment and follow-up • Abnormal values suggest possibility of diabetes and should lead to consultation with an internist • Fasting glucose ≥ 126 mg/dl; random plasma glucose >200mg/dl, hemoglobin A 1c > 6.1%
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