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Monitoring the metabolic side-effects of atypical antipsychotics

  • Rohit Gumber (a1), Mizrab Abbas (a1) and Manjunath Minajagi (a1)
Abstract
Aims and method

National clinical guidance states that patients on antipsychotics should have their metabolic profile regularly monitored. The aim of this study was to assess whether we are effectively monitoring metabolic profiles and to improve the detection, communication and intervention of metabolic abnormalities among patients on atypical antipsychotics. We describe a full audit cycle.

Results

The audit resulted in a 24% increase in the number of patients on atypical antipsychotics being referred to the metabolic clinic. The number of abnormal results communicated to primary care showed a significant improvement of 25% (P <0.001), and ultimately the number of patients who received intervention improved by 17% (P = 0.001).

Clinical implications

Audit feedback has been effective in changing clinical practice. The audit demonstrated the potential value of a metabolic clinic and shared care between primary and secondary practitioners for this group of high-risk 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.
Corresponding author
Rohit Gumber (gumber@doctors.org.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 De Hert, M, Hanssens, L, Van Winkel, R, Wampers, M, Van Eyck, D, Scheen, A, et al. A case series: evaluation of the metabolic safety of aripiprazole. Schizophr Bull 2007; 33: 823–30.
2 Prescribing Observatory for Mental Health (POMH-UK). The Metabolic Side Effects of Antipsychotic Medication Represent a Serious Risk to Physical Health. POMH-UK, 2006 (http://www.rcpsych.ac.uk/pdf/T2%20info%20leaflet.pdf).
3 Barnett, AH, Mackin, P, Chaudhry, I, Farooqi, A, Gadsby, R, Heald, A, et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007; 21: 357–73.
4 Thakore, JH, Mann, JN, Vlahos, I, Martin, A, Reznek, R. Increased visceral fat distribution in drug-naive and drug-free patients with schizophrenia. Int J Obesity 2002; 26: 137–41.
5 Ryan, MC, Flanagan, S, Kinsella, U, Keeling, F, Thakore, JH. The effects of atypical antipsychotics on visceral fat distribution in first episode, drug-naive patients with schizophrenia. Life Sci 2004; 74: 19992008.
6 Zhang, ZJ, Yao, ZJ, Liu, W, Fang, Q, Reynolds, GP. Effects of antipsychotics on fat deposition and changes in leptin and insulin levels. Magnetic resonance imaging study of previously untreated people with schizophrenia. Br J Psychiatry 2004; 184: 5862.
7 International Diabetes Federation (IDF). The IDF Consensus Worldwide Definition of Metabolic Syndrome. IDF, 2006 (http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf).
8 National Library for Health. Clinical Knowledge Summaries: Schizophrenia. National Library for Health, 2007 (http://www.cks.library.nhs.uk/schizophrenia).
9 Taylor, D, Paton, C, Kerwin, R. Antipsychotics – monitoring. In The Maudsley Prescribing Guidelines (9th edn). Informa Healthcare, 2007.
10 Barnes, TRE, Paton, C, Cavanagh, MR, Hanock, E, Taylor, DM. A UK audit of screening for the metabolic side effects of antipsychotics in community patients. Schizophr Bull 2007; 33: 13971403.
11 Haupt, DW, Rosenblatt, LC, Kim, E, Baker, RA, Whitehead, R, Newcomer, JW. Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry 2009; 166: 345–53.
12 National Institute for Health and Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (CG82). NICE, 2009.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Monitoring the metabolic side-effects of atypical antipsychotics

  • Rohit Gumber (a1), Mizrab Abbas (a1) and Manjunath Minajagi (a1)
Submit a response

eLetters

Let's target our screening more effectively.

Paul F Reed, Consultant Psychiatrist
09 October 2010

I was very interested in the paper of Gumber et al1 which examined the monitoring of metabolic side effects of antipsychoticsin patients with schizophrenia. I commend them for their attempts to follow guidance for this monitoring. I agree that metabolic side effects are important considerations for this group of patients. However, my critical review of the evidence of risk to mentally ill patients does not support the use of such widespread monitoring.

I will use the example of lipid monitoring to illustrate this.

A large general practice study in the UK2 found the relative risk of death from cardiovascular disease in mentally ill people when compared to controls was highest in younger peopleand reduced with age to a point that was not statistically significant in people over the age of 75 years. The authors of that study claim the 3 fold increase in deaths for people underthe age of 50 is the most worrying. This may be so , but the finding is worthy of closer scrutiny , especially when the implications for screening are being considered.

In fact the absolute risk of death from coronary heart disease mentally ill people age 18-49 was 0.1% over a median follow up period of 4.7 years.

European guidelines3 for prevention of heart disease recommend monitoring of lipids only when the 10 year risk reaches 5% or more. It would seem difficult therefore to justify routine monitoring of mentally ill people age 18-49 .

Also of concern is the lack of evaluation of harm to patients caused by what is essentially a screening programme of high risk individuals. Such programmes are known to be associated with harm in a variety of forms. These include overdiagnosis , overtreatment and anxiety concerning the illness being investigated4.

Lastly , in order for a patient to give informed consent to participate in this kind of programme they should be informed of the uncertainties inherent in it and the likelihood or otherwise of benefit to them of such screening.

I argue it is time to take stock and critically review which , if any of these investigations are necessary for our patients.

1 Gumber R Mizrab A, Minajagiet M. Monitoring the metabolic side- effects of atypical antipsychotics The Psychiatrist 2010, 34: 390-395

2 Osborn DP, Levy G, Nazareth I, Petersen I, Islam A, King MB. Relativerisk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007;64(2):242-9.

3 Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.European guidelines on cardiovascular disease prevention in clinicalpractice: executive summary. Eur J Cardiovasc Prevent Rehabil 2007;14(Suppl. 2):E1-40.

4 Jørgensen K, Gøtzsche P Content of invitations for publicly funded Screening mammography BMJ 2006;332:538-41
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