Exploring the risk of diabetes mellitus and dyslipidemia among ambulatory users of atypical antipsychotics: a population-based comparison of risperidone and olanzapine

Reduction in Multiple Cardiometabolic Risk Factors With Combined Olanzapine/Samidorphan Compared With Olanzapine: Post Hoc Analyses From a 24-Week Phase 3 Study

BACKGROUND AND HYPOTHESES

Weight gain and adverse cardiometabolic effects often limit the clinical utility of olanzapine. In ENLIGHTEN-2, combining olanzapine with the opioid receptor antagonist samidorphan (OLZ/SAM) mitigated olanzapine-associated weight gain. These analyses tested the hypothesis that OLZ/SAM would be associated with reduced adverse cardiometabolic effects compared with olanzapine.

STUDY DESIGN

This phase 3 double-blind study randomized adults with schizophrenia to OLZ/SAM or olanzapine for 24 weeks. Post hoc analyses assessed changes from baseline to week 24 in cardiometabolic risk parameters, including body mass index (BMI), risk of developing obesity (BMI ≥30 kg/m2) or metabolic syndrome, waist circumference, along with mean and potentially clinically significant changes in blood pressure, glucose, and lipids.

RESULTS

After 24 weeks' treatment, compared with olanzapine, OLZ/SAM was associated with smaller least-squares mean (LSM) changes from baseline in systolic blood pressure (LSM difference, -2.63 mm Hg; 95% CI: -4.78, -0.47), diastolic blood pressure (LSM difference, -0.75 mm Hg; 95% CI: -2.31, 0.80), and BMI (LSM difference, -0.65 kg/m2; 95% CI: -1.01, -0.28). OLZ/SAM treatment was also associated with reduced risk of shifting from normal blood pressure to stage 1/2 hypertension (odds ratio [OR], 0.48; 95% CI: 0.24, 0.96), becoming obese (OR, 0.52; 95% CI: 0.32, 0.82), and developing metabolic syndrome (OR, 0.55; 95% CI: 0.31, 0.99) compared with olanzapine. No treatment group differences were noted for risk of hyperglycemia or hyperlipidemia.

CONCLUSIONS

OLZ/SAM treatment was associated with lower risk of worsening cardiometabolic risk factors related to obesity, hypertension, and metabolic syndrome relative to olanzapine. NCT02694328, https://clinicaltrials.gov/ct2/show/NCT02694328.

An Evidence-Based Review of OLZ/SAM for Treatment of Adults with Schizophrenia or Bipolar I Disorder

Olanzapine effectively treats schizophrenia and bipolar I disorder (BD-I); however, its use is limited by the risk of significant weight gain and metabolic effects. OLZ/SAM, a combination of olanzapine and samidorphan, was recently approved in the United States for the treatment of adults with schizophrenia or BD-I. OLZ/SAM provides the efficacy of olanzapine while mitigating olanzapine-associated weight gain through opioid-receptor blockade. Here, we summarize OLZ/SAM clinical data characterizing pharmacokinetics, antipsychotic efficacy, weight mitigation efficacy, safety, and long-term treatment effects. In an acute exacerbation of schizophrenia, OLZ/SAM and olanzapine provided similar symptom improvements versus placebo at week 4. In stable outpatients with schizophrenia, OLZ/SAM treatment resulted in significantly less weight gain, reducing the risk for clinically significant weight gain and waist circumference increases of ≥5 cm by half, compared with olanzapine at week 24. Based on open-label extension studies, OLZ/SAM is safe and well tolerated for up to 3.5 years of treatment, while maintaining schizophrenia symptom control and stabilizing weight. The olanzapine component of OLZ/SAM was bioequivalent to branded olanzapine (Zyprexa); adjunctive OLZ/SAM had no clinically significant effects on lithium or valproate pharmacokinetics. Additionally, OLZ/SAM had no clinically relevant effect on electrocardiogram parameters in a dedicated thorough QT study. Overall, safety and tolerability findings from clinical studies with OLZ/SAM indicate a similar safety profile to that of olanzapine, with the exception of less weight gain. As OLZ/SAM contains the opioid antagonist samidorphan, it is contraindicated in patients using opioids and in those undergoing acute opioid withdrawal. Clinical trial results from more than 1600 subjects support the use of OLZ/SAM as a new treatment option for patients with schizophrenia or BD-I.

Risk of Treatment-Emergent Diabetes Mellitus in Patients Receiving Antipsychotics

Background:

Type 2 diabetes mellitus has been reported during antipsychotic treatment.

Objective:

To quantify the potential risk of treatment-emergent diabetes mellitus among patients receiving antipsychotic medications.

Methods:

The MEDLINE and Psychinfo databases were searched using the key words antipsychotic (including individual drug names), diabetes, risk, and incidence for all English-language articles published between 1966 and 2005. Risk calculations were performed using data obtained from pharmacoepidemiologic studies that met the following criteria: (1) cohort design, (2) determination of preexisting diabetes, (3) inclusion of antipsychotic monotherapy as an exposure variable, and (4) comparison with exposure to first-generation antipsychotics. Studies meeting these criteria were used to calculate incidence, attributable risk between agents, and number needed to harm.

Results:

A total of 25 observational pharmacoepidemiologic studies were found comparing antipsychotics on the outcome of diabetes mellitus. Sufficient information was provided in 15 of the reports to be able to estimate attributable risk, Attributable risk for individual second-generation antipsychotics relative to first-generation antipsychotics ranged from 53 more to 46 fewer new cases of diabetes per 1000 patients. Little observable difference was noted between the individual second-generation antipsychotics versus first-generation antipsychotics on this outcome. However, few of the studies controlled for body weight, race or ethnicity, or the presence of diabetogenic medications. None adjusted for familial history of diabetes, levels of physical activity, or diet, as this information is not usually available in the databases used in pharmacoepidemiologic studies.

Conclusions:

Based on the published pharmacoepidemiologic reports reviewed, the avoidance of diabetes as an outcome cannot be predictably achieved with precision by choice of a second- versus a first-generation antipsychotic. Risk management for new-onset diabetes requires the assessment of established risk factors such as family history, advancing age, non-white ethnicity, diet, central obesity, and level of physical activity.

Post authorization safety study comparing quetiapine to risperidone and olanzapine

OBJECTIVES

To compare rates of specific adverse outcomes between patients starting quetiapine, olanzapine, or risperidone use in the Netherlands.

METHODS

Observational study using the PHARMO Database Network, including patients starting quetiapine (4658), olanzapine (5856), or risperidone (7229) in 2000-2009, comparing rates of all-cause mortality, failed suicide attempts, extrapyrimidal symptoms (EPS), diabetes mellitus (DM), hypothyroidism, and acute myocardial infarction (AMI).

KEY FINDINGS

Median follow-up until discontinuation/end of follow-up was 0.6 years. Prescribed doses were generally lower than the approved defined daily doses, especially for quetiapine. Quetiapine was significantly associated with lower EPS rates (HR 0.18; 95% CI 0.13-0.24), but higher failed suicide attempt rates (HR 2.07; 95% CI 1.35-3.16) compared to risperidone. Quetiapine was significantly associated with lower EPS rates (HR 0.59; 95% CI 0.42-0.84) and DM rates (HR 0.66; 95% CI 0.44-0.97) compared to olanzapine. Rates for all-cause mortality, hypothyroidism, and stroke were similar between groups. AMI events were too infrequent to draw conclusions.

CONCLUSIONS

Quetiapine was associated with lower EPS, but higher failed suicide attempt rates compared to risperidone. Quetiapine was associated with lower EPS and DM rates compared to olanzapine. The results should be interpreted with caution because of possible channelling and residual confounding. Copyright © 2016 John Wiley & Sons, Ltd.

The utility of behavioral economics in expanding the free-feed model of obesity

Animal models of obesity are numerous and diverse in terms of identifying specific neural and peripheral mechanisms related to obesity; however, they are limited when it comes to behavior. The standard behavioral measure of food intake in most animal models occurs in a free-feeding environment. While easy and cost-effective for the researcher, the free-feeding environment omits some of the most important features of obesity-related food consumption-namely, properties of food availability, such as effort and delay to obtaining food. Behavior economics expands behavioral measures of obesity animal models by identifying such behavioral mechanisms. First, economic demand analysis allows researchers to understand the role of effort in food procurement, and how physiological and neural mechanisms are related. Second, studies on delay discounting contribute to a growing literature that shows that sensitivity to delayed food- and food-related outcomes is likely a fundamental process of obesity. Together, these data expand the animal model in a manner that better characterizes how environmental factors influence food consumption.

Comparative safety of antipsychotics: another look at the risk of diabetes

OBJECTIVE

The association between the use of antipsychotics and diabetes mellitus (DM) is still unclear, as depicted by several conflicting reports. Our study aims to assess the risk of DM in new users of antipsychotics.

METHODS

Our nested case-control study used the Quebec Health Insurance Board databases. People in the source cohort were DM-free and had initiated an antipsychotic treatment. Subjects were cohort members who initiated an antidiabetic or had a diagnosis of DM during their follow-up period. Three variables were used to assess antipsychotic exposure: the antipsychotic used (any typical, clozapine, olanzapine, quetiapine, risperidone, or more than 1 drug); the number of 30-day periods of use; and antipsychotic use at index date (current or past). A paired multivariate logistic regression model was used to calculate adjusted odds ratios.

RESULTS

Among the 88 467 people included in the cohort, 6109 subjects with DM were identified and were matched to 61 090 control subjects. New users of quetiapine were less likely to develop DM than new users of typical antipsychotics (OR, 0.89; 95% CI 0.81 to 0.99). The risk of DM was not statistically different across the atypical antipsychotics. A longer exposure to any antipsychotic (for each 30-day period, OR 1.009; 95% CI 1.006 to 1.011) and current use of antipsychotics (OR 1.26; 95% CI 1.17 to 1.36) were associated with DM.

CONCLUSION

These results suggest that metabolic parameters of people exposed to antipsychotics should be monitored, irrespective of the drug taken, among the drugs available at the time of analysis.

Fatal diabetic ketoacidosis and antipsychotic medication

Hyperglycemia and new onset diabetes have been described with certain antipsychotic medications and some of the initial presentations are fatal diabetic ketoacidosis (DKA). We report 17 deaths due to DKA in psychiatric patients treated with second generation antipsychotic medications. Death certificates and toxicology data were searched for DKA and hyperglycemia. We reviewed the medical examiner records which included the autopsy, toxicology, police, and medical examiner investigators' reports. The decedents ranged in age from 32 to 57 years (average 48 years). There were 15 men and two women. The immediate cause of death was DKA in all. The psychiatric disorders included: 10 schizophrenia, three bipolar/schizophrenia, two bipolar, and two major depression. The most frequent atypical antipsychotic medications found were quetiapine and olanzapine followed by risperidone. In 16 deaths, we considered the medication as primary or contributory to the cause of death.

Antipsychotic medication use among children and risk of diabetes mellitus

OBJECTIVE

To assess whether the risk of incident diabetes was increased with the use of second-generation antipsychotics (SGAs) in a large diverse cohort of children.

METHODS

A retrospective study was conducted by using the administrative databases of 3 health plans participating in the Health Maintenance Organization Research Network. Children 5 to 18 years of age who initiated SGA therapy between January 2001 and December 2008 and 2 comparison groups, namely, nonusers of psychotropic drugs and users of antidepressant medications, were identified. Diagnoses from inpatient and outpatient records, pharmacy dispensings, and outpatient laboratory results were used to identify incident cases of diabetes.

RESULTS

The crude incidence rate of diabetes for the SGA-exposed cohort was 3.23 cases per 1000 person-years (95% confidence interval [CI]: 1.67-5.65), compared with 0.76 cases per 1000 person-years (95% CI: 0.49-1.12) among nonusers of psychotropic medications and 1.86 cases per 1000 person-years (95% CI: 1.12-2.90) among antidepressant users. The risk of incident diabetes was significantly increased among SGA users (unadjusted incidence rate ratio: 4.24 [95% CI: 1.95-8.72]) in comparison with nonusers of psychotropic medications but was not significantly increased in comparison with antidepressant medication users (unadjusted incidence rate ratio: 1.74 [95% CI: 0.77-3.78]).

CONCLUSIONS

Although we found a potentially fourfold increased rate of diabetes among children exposed to SGAs, the findings were inconsistent and depended on the comparison group and the outcome definition.

A critical appraisal of treatments for bipolar disorder

Recovery-the absence of all abnormal mood symptoms-is the goal of treatment for bipolar disorder. Unfortunately, a minority of people suffering from bipolar disorder achieve sustained recovery. Improving recovery rates for this population will require clinicians in the primary care setting to be familiar with appropriate treatments for acute bipolar mania and depression and for the maintenance phase. Efficacy and tolerability of pharmacotherapeutic and psychotherapeutic options for all phases of treatment and each type of mood episode are discussed. Primary care physicians are encouraged to avoid prescribing antidepressant monotherapy for any patient with depression and a history of mania or hypomania.

Drug-Induced Endocrine and Metabolic Disorders

Complex interactions exist amongst the various components of the neuroendocrine system in order to maintain homeostasis, energy balance and reproductive function. These components include the hypothalamus-pituitary- adrenal and -gonadal axes, the renin-angiotensin-aldosterone system, the sympathetic nervous system and the pancreatic islets. These hormones, peptides and neurotransmitters act in concert to regulate the functions of many organs, notably the liver, muscles, kidneys, thyroid, bone, adrenal glands, adipocytes, vasculature, intestinal tract and gonads, through many intermediary pathways. Endocrine and metabolic disorders can arise from imbalance amongst numerous hormonal factors. These disturbances may be due to endogenous processes, such as increased secretion of hormones from a tumour, as well as exogenous drug administration. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the hormonal axis, effects on hormonal transport, binding, and signalling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can affect the evaluation of endocrine parameters by causing interference with diagnostic tests. Common drug-induced endocrine and metabolic disorders include disorders of carbohydrate metabolism, electrolyte and calcium abnormalities, as well as drug-induced thyroid and gonadal disorders. An understanding of the proposed mechanisms of these drug effects and their evaluation and differential diagnosis may allow for more critical interpretation of the clinical observations associated with such disorders, better prediction of drug-induced adverse effects and better choices of and rationales for treatment.

Epidemiological impact of antidepressant and antipsychotic drugs on the general population

PURPOSE OF REVIEW

To analyse the prevalence of and sex and age distribution associated with antidepressant and antipsychotic drug exposure in the general population and to highlight recent epidemiological findings concerning specific adverse outcomes associated with drug exposure.

RECENT FINDINGS

Epidemiological studies indicate high rates of second-generation antidepressant and antipsychotic drug use in the general population. The use is more prevalent among women than among men, and in older rather than in younger age groups. A new pattern of adverse outcomes has been described in individuals exposed to newer agents, including a possible risk of suicidal acts in adults receiving second-generation antidepressants, the risk of cerebrovascular events in older individuals receiving second-generation antipsychotics and the risk of metabolic disturbances in individuals exposed to specific second-generation antipsychotics.

SUMMARY

The assessment of, and attention to, the development of specific adverse reactions in individuals exposed to second-generation psychotropic drugs may improve treatment outcomes.

Treatment of schizophrenia patients: comparing new-generation antipsychotics to each other

PURPOSE OF REVIEW

Although the debate on whether new antipsychotics have advantages over the old neuroleptics has recently been refueled by the first publication of the Clinical Antipsychotic Trials of Intervention Effectiveness results, one of the new challenges in the pharmacological management of schizophrenia patients is to choose among the new-generation drugs.

RECENT FINDINGS

Earlier work has compared these medications primarily to traditional antipsychotics and until very recently there was little published information on the relative efficacy/safety of new-generation antipsychotics.

SUMMARY

This review covers studies wherein therapeutic effects and adverse events of these drugs in schizophrenia patients were compared in head-to-head studies and that were published in 2005. Information is clearly more homogenous on the safety profile side, while the available evidence still offers little help for the clinicians' daily struggles to find the optimally effective antipsychotic for an individual schizophrenia patient.

Tuberous Xanthomas Associated with Olanzapine Therapy and Hypertriglyceridemia in the Setting of a Rare Apolipoprotein E Mutation

OBJECTIVE

To describe a patient with tuberous xanthomas and high levels of cholesterol and triglycerides, who was found to have type III hyperlipoproteinemia (HLP) and a rare apolipoprotein E (apoE) mutation.

METHODS

We present a case report with extensive clinical, laboratory, and genetic documentation.

RESULTS

A 33-year-old African American man presented for evaluation of hypertriglyceridemia. His medical history was remarkable for schizophrenia necessitating ongoing olanzapine therapy for the past 6 years. A few months after olanzapine treatment was begun, he noted the development of nontender, firm, papular skin lesions on his elbows and knees. His family history was negative for lipid disorders or premature vascular disease. Physical examination revealed the presence of prominent tuberous xanthomas on both elbows and knees. Results of a lipid panel demonstrated a total cholesterol level of 374 mg/dL (9.7 mmol/L) and triglycerides of 828 mg/dL (9.3 mmol/L). A work-up for causes of secondary hyper-triglyceridemia was negative. Results of apoE genotyping by a commercial laboratory showed the E3/E3 genotype, based on gene sequencing at codons 112 and 158. Because the skin lesions were typical for type III HLP, his entire apoE gene was sequenced. This analysis revealed an apoE2/E2 (arginine 145 to cysteine) mutation, previously reported to be a rare cause of type III HLP in 5 patients of African descent. Triglyceride-lowering therapy with gem-fibrozil was initiated, in addition to lifestyle modification. At follow-up several months later, total cholesterol was 276 mg/dL (7.14 mmol/L) and triglycerides were 479 mg/dL (5.41 mmol/L).

CONCLUSION

We speculate that olanzapine therapy, with its known metabolic side effects, exacerbated this patient's underlying lipoprotein metabolic abnormality. To our knowledge, this is the first report of an association between olanzapine therapy and tuberous xanthomas and the sixth report of this rare apoE2/E2 (arginine 145 to cysteine) mutation in the literature.

Minimising the risk of diabetes in patients with schizophrenia and bipolar disorder

Objective. Patients with schizophrenia and bipolar disorder demonstrate a higher prevalence of abnormalities of glucose metabolism and are at risk of developing type 2 diabetes. Certain antipsychotics may unmask or exacerbate abnormalities of glucose metabolism. Type 2 diabetes is associated with considerable morbidity and mortality; therefore, minimising the risk of developing diabetes is of significant importance for the long-term health of patients. Methods. A search of studies published between January 1975 and November 2005 was performed. Results. Based on the evidence reviewed, clinical strategies are suggested for limiting the risk of developing diabetes in patients with schizophrenia or bipolar disorder. Epidemiological studies examining the risk of diabetes in patients treated with atypical antipsychotics are also examined in addition to mechanistic studies investigating how these effects might occur. Conclusion. An increased risk of diabetes with some atypical antipsychotics should not deter physicians from using these agents in patients with schizophrenia or bipolar disorder, but it is recommended that antipsychotic therapy be carefully selected in those patients at greatest risk of developing diabetes or metabolic syndrome. Appropriate management and regular monitoring of patients receiving antipsychotics should minimise the risk of patients with schizophrenia or bipolar disorder developing diabetes.

Ambulatory use of olanzapine and risperidone: a population-based study on persistence and the use of concomitant therapy in the treatment of schizophrenia

OBJECTIVE

To assess treatment discontinuation and concomitant use of other antipsychotics among individuals initiated on olanzapine or risperidone for the treatment of schizophrenia.

METHOD

Using data from the Quebec health insurance plan and the Quebec database for hospitalization, we conducted a population-based cohort study of patients for whom a first claim for olanzapine or risperidone was submitted between 1 January 1997 and 31 August 1999. Included were 6405 patients with schizophrenia whom we followed from the date of the first claim for olanzapine or risperidone either to discontinuation date, end of eligibility for the drug plan, 365 days, date of moving out of the province, or date of death. We used Cox regression models to compute hazards ratios (HRs) of having the treatment discontinued and logistic regression models to compute odds ratios (ORs) among persisting patients of having any concomitant antipsychotic prescription. All models were adjusted for age, sex, schizophrenia disorder, comorbidity, region, beneficiary type, substance use disorder, and prior hospitalization for mental illness.

RESULTS

Compared with risperidone users (n = 2718), discontinuation rates were lower for olanzapine users (n = 3687; HR = 0.79; 95%CI, 0.74 to 0.84). The odds of receiving any concomitant antipsychotic prescription did not differ statistically between olanzapine and risperidone users (OR 0.85; 95%CI, 0.71 to 1.01).

CONCLUSIONS

The study results suggest that new users of olanzapine were less likely to discontinue their initial treatment than were new users of risperidone, although discontinuation was high in both groups. Among those who persisted, concomitant use of other antipsychotics did not differ between olanzapine users and risperidone users.