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Blood glucose testing for adults prescribed atypical antipsychotics in primary and secondary care

  • Catharine Jane Tarrant (a1)
Abstract
Aims and Method

The routine monitoring of blood glucose indices for all patients on atypical antipsychotics in 2004 in a rural adult psychiatric sector was examined. Pragmatic and practical standards were based on consensus expert opinion, National Institute for Clinical Excellence and prescribing guidelines.

Results

The audit was completed on 60 atypical antipsychotic prescriptions. Testing of blood glucose prior to the initiation or change of an atypical antipsychotic was largely followed, with an overall adherence rate of 82%. However, there were large differences in testing between in-patient and community settings. Routine yearly monitoring in the community was inadequate, with an adherence rate of 63%.

Clinical Implications

There is a welcome emphasis on the physical health of those with severe and enduring mental illness. New initiatives, including prescribing guidelines, the care programme approach and primary care registers, offer the opportunity to develop consistency and coordination between primary and secondary care in the routine monitoring of psychiatric treatments and physical health in these patients.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Britishmedical Association (2004) Quality and Outcomes Framework Guidance. Section 2: Clinical Indicators. Mental Health. London: BMA. http://www.bma.org.uk/ap.nsf/Content/QualityOutcomes~clinical~mh
Bushe, C. & Holt, R. (2004) Prevalence of diabetes and impaired glucose tolerance in patients with schizophrenia. British Journal of Psychiatry, 84 (suppl. 47), s67s71.
Citrome, L., Jaffe, A., Levine, J., et al (2004) Relationship between antipsychotic medication treatment and new cases of diabetes among psychiatric in-patients. Psychiatric Services, 55, 10061013.
Connolly, M. & Kelly, C. (2005) Lifestyle and physical health in schizophrenia. Advances in Psychiatric Treatment, 11, 125132.
Expert Group (2004) ‘Schizophrenia and Diabetes 2003’ Expert Consensus Meeting, Dublin 3–4 October 2003: consensus summary. British Journal of Psychiatry, 184 (suppl. 47), s112s114.
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National Institute for Clinical Excellence (2002b) The Clinical Effectiveness and Cost Effectiveness of Newer Atypical Antipsychotic Drugs for Schizophrenia (Technology Appraisal 43). http://www.nice.org.uk/page.aspx?o=ta043
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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Blood glucose testing for adults prescribed atypical antipsychotics in primary and secondary care

  • Catharine Jane Tarrant (a1)
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eLetters

Sridhar Shanmugham, SHO
26 February 2007

The above paper by Dr.Tarrant also raises an important issue of the monitoring of physical health needs in psychiatric patients.This is felt acutely in certain sub-specialties eg:psychogeriatrics,drug and alcohol.One of the impediments is the general deskilling of psychiatric trainess with regards to physical medicine.Unlike with psychiatric problems,approaching senior colleagues with physical problems of patients may not always be productive.Approaching medical registrars is generally useful though on occasions one does encounter medics who feel that their time is being wasted.Personally,I have found it extremely useful to attend medical ward rounds by arrangement during my posts.Using 4 hours of my time fortnightly helps to keep me upto date with the medical skills but also to nurture relationships wth colleagues whose advice is often useful.Overall,it has helped to raise the standard of physical healthcare of patients under my care.I would certainly suggest that this facility is made available for more trainees especially to those in psychogeriatric posts.

References:

Health Status of Individuals With Serious Mental Illness (Schizophrenia Bulletin,February 2006)Faith B. Dickerson 1 *, Clayton H. Brown 2, Gail L. Daumit 3, Fang LiJuan 4, Richard W. Goldberg 5, Karen Wohlheiter 4, and Lisa B. Dixon 5

Are psychiatrists real doctors? A survey of the medical experience and training of psychiatric trainees in the west of Scotland Laura Robinson, Senior House Officer(Psychiatric Bulletin,2005)
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Conflict of interest: None Declared

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The knowledge-practice gap in metabolic monitoring of antipsychotic usage

Lena K Palaniyappan, Senior House Officer
31 August 2006

Dr.Tarrant's findings (Tarrant, 2006) in both inpatient and outpatient population from Derbyshire reports a 100% baseline monitoring for glucose before initiating atypicals for an inpatient. Interestingly a survey of the same inpatient population (Derby City Hospital - 4 acute adult admisssion wards) between October and November 2005 using retrospective case note search and lab data analysis for all current admissions (n=96) revealed 65 events, defined as initiation, change or increase (after a stable period of response - not routine titration) in dose of atypicals (Gillespie & Palaniyappan, 2006). Only 39 out of 65 potential instances of a change in metabolic parameters had a record of random or fasting glucose, 10 had lipid levels sought and 58 had blood pressure recorded. There was no record of BMI or attempts to measure waist circumference. The family or personal history of potential metabolic disease was sought at only 4 instances.

Though it is demonstarted that the outpatient population receive poorer physical health monitoring than psychiatric inpatients, the inpatient state is far from being good.The discrepancy between Tarrant's findings and ours could be due to the fact that we included the monitoring attempt only if it could be related temporally to potential metabolic issues related to schizophrenia and atypical usage. There are definite reports ofDKA with atypicals (Citrome & Jaffe, 2003). But there is a lack of clear guidelines stating when should the blood monitoring be actually doneand could a routine sampling months before prescribing atypicals be considered as a baseline measure. We considered +/-10 days as an absolute minimum time period between prescription and monitoring to make pragmatic sense of the effort of metabolic monitoring, as the earliest cases of DKA develop in 2nd week of prescription. We also dropped data if antipsychoticusage was for lesser than this time period due to any reason. Also we utilized the local Trust guidelines apart from amalgamated consensus of American, British and Australian expert groups (American Diabetic Association et al, 2004; Lambert & Chapman, 2004;UK Expert Group, 2004) to design the data collection - with 3 months as follow up period, not 4 months as in Tarrant's report. Only 8.33% of eligible events had anymetabolic followup.Extending the data to numbers potentially missed, atleast 2 hyperglycaemics, 8 hyperlipidaemics and 1 hypertensive were missed from a group of 69 inpatients prescribed antipsychotics at a cross-section. The significant diference between weight and Blood pressure measures compared to glucose and lipids and BMI suggested that simplicity of measurements could be a factor determining monitoring compliance. Considering the practical ease of capillary glucose measurement, there is a place to consider simplifying our protocols and include finger prick tests while monitoring (Sandbæk et al, 2005).

What is striking from these two samples from the same population is the gap between awareness and practice related to metabolic syndrome in schizophrenia. The clinicians are acutely aware of these complications as reflected by higher rates of screening pertaining to Olanzapine and Clozapine. The clozapine effect atleast can be partially explained by availability of blood sample making moitoring easier and patient's awareness of weight gain as a potential risk. Inspite of this knowledge among clinicians, monitoring rates are far from adequate. Perhaps it is time for us to think about simplifying monitoring protocols and paying more attention to discussing metabolic problems with patients and carers which will undoubtedly increase monitoring rates.

References:

American Diabetic Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity (2004). Consensus Development Conference on Antipsychotic drugs and Obesity and Diabetes. Diabetes Care,27,596-601

Citrome, LL., Jaffe, AB. (2003) Relationship of atypical antipsychotics with development of diabetes mellitus. Annals of Pharmacotherapy,37,1849-57

Expert group (2004). ‘Schizophrenia and Diabetes 2003’ Expert Consensus meeting, Dublin, 3-4 October 2003: Consensus summary. British Journal of Psychiatry,184 (suppl. 47), s112-s114

Gillespie, SF., Palaniyappan, LK.(2006) Baseline monitoring for metabolic abnormalities related to antipsychotic usage: Survey of adult acute admission wards. Abstract: Annual Conference of Royal College of Psychiatrists, July 10-13, Glasgow,UK.

Lambert, TJR., Chapman, LH. (2004). The Medical Journal of Australia,181, 544-548.Marder SR, Essock SM., et al(2004). Physical health monitoring of patientswith schizophrenia. American Journal of Psychiatry,161, 1334-1349

Sandbæk, A., Lauritzen, T., Borch-Johnsen, K. et al (2005). The comparison of venous plasma glucose and whole blood capillary glucose in diagnoses of Type 2 diabetes: a population-based screening study. DiabeticMedicine, 22, 1173-1177.

Tarrant, CJ.(2006) Blood glucose testing for adults prescribed atypical antipsychotics in primary and secondary care. Psychiatric Bulletin,30,286-288.

Gillespie, SF., Palaniyappan, LK.(2006) Baseline monitoring for metabolic abnormalities related to antipsychotic usage: Survey of adult acute admission wards. Abstract: Annual Conference of Royal College of Psychiatrists, July 10-13, Glasgow,UK.
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Conflict of interest: None Declared

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Monitoring of adults prescribed atypical antipsychotics

Kunal Kala, Senior House Officer
31 August 2006

Patients with mental illness have a disproportionate amount of physical morbidity and mortality.Dr Tarrants audit revealed some expected results. However it is important to note that random blood glucose tests on their ownhave are associated with high fasle negative rates (40-95%) resulting in afailure to detect a significant number of cases of type 2 diabetes mellitus (Thakore, 2005). There are no recent UK guidelines for people prescribed atypical antipsychotics, but its widely accepted that any such guidelines should include regular monitoring for the metabolic syndrome (American Diabetic Association, 2004).

They suggest monitoring:

1. Personal and family history of obesity diabetes, dyslipidemia, hypertension, or cardiovascular disease

2. Weight and height (so that BMI can be calculated)

3. Waist circumference (at the level of the umbilicus)

4. Blood pressure

5. Fasting plasma glucose

6. Fasting lipid profile

Dr Tarrant's suggestion of including regular monitoring of these parameters in CPAs would make it easier to audit them in the future and implementing shared care aproaches could improve communication with primary care.

References

American Diabetic Association (2004) Consensus Development Conferenceon Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care, 27, 596 -601

Catharine, J. T. (2006) Blood glucose testing for adults prescribed atypical antipsychotics in primary and secondary care. Psychiatric Bulletin (2006) 30: 286-288

NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2002b) The Clinical Effectiveness and Cost Effectiveness of Newer Atypical Antipsychotic Drugsfor Schizophrenia (Technology Appraisal 43)

Thakore, J. H. (2005) Metabolic syndrome and schizophrenia. British Journal of Psychiatry, 186, 455 -456
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Conflict of interest: None Declared

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