Differential effects of antipsychotic agents on the risk of development of type 2 diabetes mellitus in patients with mood disorders

Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State

BACKGROUND

Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations.

OBJECTIVE

This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state.

DISCUSSION

Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit.

CONCLUSIONS

Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Atypical Antipsychotics Augmentation in Patients with Depressive Disorder and Risk of Subsequent Dementia: A Nationwide Population-Based Cohort Study

BACKGROUND

While atypical antipsychotic medications are widely used for treating depressive disorders, their long-term effects on the risk of subsequent dementia have not been studied adequately.

OBJECTIVE

To investigate whether the risk of dementia differs according to the use of atypical antipsychotic drugs, and compare the effects of antipsychotic agents on dementia risk in individuals with late-life depressive disorders.

METHODS

A nationwide population-based retrospective cohort study was conducted using data from the National Health Insurance Service-Senior Cohort of South Korea. Atypical antipsychotic dosages were standardized using a defined daily dose, and the cumulative dosage was calculated. Participants were observed from January 2008 to December 2015. Cox proportional hazard regression analysis was used to estimate the hazard ratios.

RESULTS

The cohort included 43,788 elderly adults with depressive disorders: 9,901 participants (22.6%) were diagnosed with dementia. Findings showed that atypical antipsychotics were prescribed to 1,967 participants (4.5%). Compared with non-users, users of atypical antipsychotics experienced a significantly higher risk for dementia with an adjusted hazard ratio (aHR) of 1.541 (95% confidence interval [CI], 1.415-1.678). A cumulative dose-response relationship was observed (test for trend, p < 0.0001). Among atypical antipsychotics, risperidone displayed the highest risk for dementia (aHR 1.767, [95% CI, 1.555-2.009]).

CONCLUSION

In this study of elderly individuals with depressive disorders, atypical antipsychotic use was associated with a significantly higher risk of subsequent dementia. Healthcare professionals should be aware of this potential long-term risk. A limitation that should be mentioned is that we could not exclude patients with bipolar depression.

Diabetes mellitus risk for 102 drugs and drug combinations used in patients with bipolar disorder

OBJECTIVE

To compare the largest set of bipolar disorder pharmacotherapies to date (102 drugs and drug combinations) for risk of diabetes mellitus (DM).

METHODS

The IBM MarketScan® database was used to retrospectively analyze data on 565,253 adults with bipolar disorder without prior glucose metabolism-related diagnoses. The pharmacotherapies compared were lithium, mood-stabilizing anticonvulsants, antipsychotics, and antidepressants (monotherapy and multi-class polypharmacy). Cox regression modeling included fixed pre-treatment covariates and time-varying drug exposure covariates to estimate the hazard ratio (HR) of each treatment versus "No drug".

RESULTS

The annual incidence of new-onset diabetes during the exposure period was 3.09 % (22,951 patients). The HR of drug-dependent DM ranged from 0.79 to 2.37. One-third of the studied pharmacotherapies, including most of the antipsychotic-containing regimens, had a significantly higher risk of DM compared to "No drug". A significantly lower DM risk was associated with lithium, lamotrigine, oxcarbazepine and bupropion monotherapies, selective serotonin reuptake inhibitors (SSRI) mono-class therapy and several drug combinations containing bupropion and an SSRI. As additional drugs were combined in more complex polypharmacy, higher HRs were consistently observed.

CONCLUSIONS

There is an increased risk of diabetes mellitus associated with antipsychotic and psychotropic polypharmacy use in bipolar disorder. The evidence of a lower-than-baseline risk of DM with lamotrigine, oxcarbazepine, lithium, and bupropion monotherapy should be further investigated.

Risk of weight gain for specific antipsychotic drugs: a meta-analysis

People with schizophrenia are at considerably higher risk of cardiometabolic morbidity than the general population. Second-generation antipsychotic drugs contribute to that risk partly through their weight gain effects, exacerbating an already high burden of disease. While standard ‘as-randomized’ analyses of clinical trials provide valuable information, they ignore adherence patterns across treatment arms, confounding estimates of realized treatment exposure on outcome. We assess the effect of specific second-generation antipsychotics on weight gain, defined as at least a 7% increase in weight from randomization, using a Bayesian hierarchical model network meta-analysis with individual patient level data. Our data consisted of 14 randomized clinical trials contributing 5923 subjects (mean age = 39 [SD = 12]) assessing various combinations of olanzapine (n = 533), paliperidone (n = 3482), risperidone (n = 540), and placebo (n = 1368). The median time from randomization to dropout or trial completion was 6 weeks (range: 0–60 weeks). The unadjusted probability of weight gain in the placebo group was 4.8% across trials. For each 10 g chlorpromazine equivalent dose increase in olanzapine, the odds of weight gain increased by 5 (95% credible interval: 1.4, 5.3); the effect of risperidone (odds ratio = 1.6 [0.25, 9.1]) was estimated with considerable uncertainty but no different from paliperidone (odds ratio = 1.3 [1.2, 1.5]).

People taking a commonly prescribed antipsychotic to treat schizophrenia have an increased risk of weight gain. Sharon-Lise Normand of Harvard Medical School in the US and colleagues analysed data from 14 randomized control trials representing almost 6000 people taking one of three antipsychotic drugs for schizophrenia, or a placebo. Using a unique statistical approach, they found that people taking the drug olanzapine had the highest risk of weight gain. People taking paliperidone had only a small risk, while there was uncertainty regarding the drug riperidone. Antipsychotic drugs can often be taken for decades, so understanding their cummulative effects on patient health is crucial to improving quality of life and preventing premature mortality. The method used in this study is unique and could be used to analyse other aspects of drug use.

Atypical antipsychotics, insulin resistance and weight; a meta-analysis of healthy volunteer studies

Atypical antipsychotics increase the risk of diabetes and cardiovascular disease through their side effects of insulin resistance and weight gain. The populations for which atypical antipsychotics are used carry a baseline risk of metabolic dysregulation prior to medication which has made it difficult to fully understand whether atypical antipsychotics cause insulin resistance and weight gain directly. The purpose of this work was to conduct a systematic review and meta-analysis of atypical antipsychotic trials in healthy volunteers to better understand their effects on insulin sensitivity and weight gain. Furthermore, we aimed to evaluate the occurrence of insulin resistance with or without weight gain and with treatment length by using subgroup and meta-regression techniques. Overall, the meta-analysis provides evidence that atypical antipsychotics decrease insulin sensitivity (standardized mean difference=-0.437, p<0.001) and increase weight (standardized mean difference=0.591, p<0.001) in healthy volunteers. It was found that decreases in insulin sensitivity were potentially dependent on treatment length but not weight gain. Decreases in insulin sensitivity occurred in multi-dose studies <13days while weight gain occurred in studies 14days and longer (max 28days). These findings provide preliminary evidence that atypical antipsychotics cause insulin resistance and weight gain directly, independent of psychiatric disease and may be associated with length of treatment. Further, well-designed studies to assess the co-occurrence of insulin resistance and weight gain and to understand the mechanisms and sequence by which they occur are required.

Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.

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.

Atypical antipsychotics and hyperglycemic emergencies: multicentre, retrospective cohort study of administrative data

OBJECTIVE

To evaluate the relationship between initiation of atypical antipsychotic agents and the risk of hyperglycemic emergencies.

METHOD

We conducted a multicentre retrospective cohort study using administrative health data from 7 Canadian provinces and the UK Clinical Practice Research Datalink. Hospitalizations for hyperglycemic emergencies (hyperglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic state) were compared between new users of risperidone (reference), and new users of olanzapine, other atypical antipsychotics, and typical antipsychotics. We used propensity scores with inverse probability of treatment weighting and proportional hazard models to estimate the site-specific hazard ratios of hyperglycemic emergencies in the year following drug initiation separately for adults under and over age 66 years. Site-level results were pooled using meta-analytic methods.

RESULTS

Among 725,489 patients, 55% were aged 66+years; 5% of younger and 19% of older patients had pre-existing diabetes. Hyperglycemic emergencies were rare (1-2 per 1000 person years), but more frequent in patients with pre-existing diabetes (6-12 per 1000 person years). We did not find a significant difference in risk of hyperglycemic emergencies with initiation of olanzapine versus risperidone; however heterogeneity existed between sites. The risk of an event was significantly lower with other atypical (99% quetiapine) compared to risperidone use in older patients [adjusted hazard ratio, 95% confidence interval (CI): 0.69, 0.53-0.90].

CONCLUSIONS

Risk for hyperglycemic emergencies is low after initiation of antipsychotics, but patients with pre-existing diabetes may be at greater risk. The risk appeared lower with the use of quetiapine in older patients, but the clinical significance of the findings requires further study.

Risperidone for bipolar disorders

Atypical antipsychotic medications are a relatively new, increasingly prominent component of the treatment armamentarium for bipolar disorder -- a development that provides more options for potentially improved outcomes for patients and families affected by bipolar disorder. The US Food and Drug Administration-approved bipolar indications for risperidone include monotherapy for the short-term treatment of acute manic or mixed episodes associated with bipolar I disorder and combination therapy with lithium or valproate for the short-term treatment of acute manic or mixed episodes associated with bipolar I disorder. Risperidone is also approved in over 30 countries worldwide for bipolar mania either as monotherapy, adjunct therapy, or both monotherapy and adjunct therapy. A number of controlled and open-label treatment trials have shown risperidone's efficacy and tolerability in the manic phase of bipolar disorder. Risperidone has also been reported to be useful in the longer-term treatment of bipolar disorder. This drug profile of risperidone for bipolar disorder will address the chemistry, pharmacodynamics, pharmacokinetics and metabolism of risperidone, clinical trials in bipolar disorder, postmarketing surveillance, safety, tolerability and regulatory issues. Finally, a discussion of potential future directions, a summary of key issues and information resources are provided.

Arsenic exposure from drinking water and QT-interval prolongation: results from the Health Effects of Arsenic Longitudinal Study

BACKGROUND

Arsenic exposure from drinking water has been associated with heart disease; however, underlying mechanisms are uncertain.

OBJECTIVE

We evaluated the association between a history of arsenic exposure from drinking water and the prolongation of heart rate-corrected QT (QTc), PR, and QRS intervals.

METHOD

We conducted a study of 1,715 participants enrolled at baseline from the Health Effects of Arsenic Longitudinal Study. We assessed the relationship of arsenic exposure in well water and urine samples at baseline with parameters of electrocardiogram (ECG) performed during 2005-2010, 5.9 years on average since baseline.

RESULTS

The adjusted odds ratio (OR) for QTc prolongation, defined as a QTc ≥ 450 msec in men and ≥ 460 msec in women, was 1.17 (95% CI: 1.01, 1.35) for a 1-SD increase in well-water arsenic (108.7 µg/L). The positive association appeared to be limited to women, with adjusted ORs of 1.24 (95% CI: 1.05, 1.47) and 1.24 (95% CI: 1.01, 1.53) for a 1-SD increase in baseline well-water and urinary arsenic, respectively, compared with 0.99 (95% CI: 0.73, 1.33) and 0.86 (95% CI: 0.49, 1.51) in men. There were no apparent associations of baseline well-water arsenic or urinary arsenic with PR or QRS prolongation in women or men.

CONCLUSIONS

Long-term arsenic exposure from drinking water (average 95 µg/L; range, 0.1-790 µg/L) was associated with subsequent QT-interval prolongation in women. Future longitudinal studies with repeated ECG measurements would be valuable in assessing the influence of changes in exposure.

Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline

CONTEXT

The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) cohort represents the largest and best-characterized national sample of American youth with recent-onset type 2 diabetes.

OBJECTIVE

The objective of the study was to describe the baseline characteristics of participants in the TODAY randomized clinical trial.

DESIGN

Participants were recruited over 4 yr at 15 clinical centers in the United States (n = 704) and enrolled, randomized, treated, and followed up 2-6 yr.

SETTING

The study was conducted at pediatric diabetes care clinics and practices.

PARTICIPANTS

Eligible participants were aged 10-17 yr inclusive, diagnosed with type 2 diabetes for less than 2 yr and had a body mass index at the 85th percentile or greater.

INTERVENTIONS

After baseline data collection, participants were randomized to one of the following groups: 1) metformin alone, 2) metformin plus rosiglitazone, or 3) metformin plus a lifestyle program of weight management.

MAIN OUTCOME MEASURES

Baseline data presented include demographics, clinical/medical history, biochemical measurements, and clinical and biochemical abnormalities.

RESULTS

At baseline the cohort included the following: 64.9% were female; mean age was 14.0 yr; mean diabetes duration was 7.8 months; mean body mass index Z-score was 2.15; 89.4% had a family history of diabetes; 41.1% were Hispanic, 31.5% were non-Hispanic black; 38.8% were living with both biological parents; 41.5% had a household annual income of less than $25,000; 26.3% had a highest education level of parent/guardian less than a high school degree; 26.3% had a blood pressure at the 90th percentile or greater; 13.6% had a blood pressure at the 95th percentile or greater; 13.0% had microalbuminuria; 79.8% had a low high-density lipoprotein level; and 10.2% had high triglycerides.

CONCLUSIONS

The TODAY cohort is predominantly from racial/ethnic minority groups, with low socioeconomic status and a family history of diabetes. Clinical and biochemical abnormalities and comorbidities are prevalent within 2 yr of diagnosis. These findings contribute greatly to our understanding of American youth with type 2 diabetes.

[Drug-induced hyperglycemia: a study in the French pharmacovigilance database]

OBJECTIVE

To analyse drugs inducing hyperglycemia by using data reported to the French spontaneous reporting system and recorded in the French PharmacoVigilance Database (FPVD).

METHODS

All cases with a report of hyperglycemia and/or diabetes in the French database between 1985 and 2008 were included in the study. We estimated the risk of hyperglycemia linked to drugs by the case/non-case method. Cases were reports including hyperglycemia and non cases all other reports. This risk was estimated through calculation of reporting odds ratios (ROR).

RESULTS

During this period, 1219 reports including the words "hyperglycemia and/or diabetes" were registered (0.34% of the database). This adverse drug reaction occurred 1 fold over 4 in diabetics or as a part of HIV infection. Effect was "serious" in approximatively 50% of cases. We found an increase of risk during exposition with methylprednisolone [ROR=43.5; 95% CI (37.3-50.8)], tacrolimus [ROR=25; 95% CI (17.9-34.8)], olanzapine [ROR=19.9; 95% CI (14.9-26.5)], prednisone [ROR=18.9; 95% CI (15.7-22.8)] or pentamidine [ROR=15.4; 95% CI (8.2-28.3)].

CONCLUSION

Drug classes most frequently found in FPVD linked to hyperglycemia are antiretroviral, steroidal anti-inflammatory, second generation neuroleptic, immunosuppressive and diuretic drugs.

Treatment with antipsychotics and the risk of diabetes in clinical practice

BACKGROUND

Treatment with antipsychotics seems to increase the risk of developing diabetes but the association is poorly characterised in clinical practice.

AIMS

To investigate and characterise the incidence of diabetes for people treated with antipsychotic medication in clinical practice.

METHOD

The study used the linkage of registers of all prescribed antipsychotics, antidiabetics and diagnoses of diabetes in Denmark during a period from 1996 to 2005 and identified all people treated with antipsychotics in Denmark and a random sample of about 30% of the total Danish population.

RESULTS

In total, 345,937 patients who purchased antipsychotics and 1,426,488 unexposed individuals were included in the study. Among the total population, 50,379 individuals subsequently developed incident diabetes. Compared with unexposed individuals, treatment with first- (rate ratio, RR = 1.53, 95% CI 1.49-1.56) as well as second-generation (RR = 1.32, 95% CI 1.22-1.42) antipsychotics was associated with increased risk of subsequent incident diabetes. The rate of incident diabetes varied substantially between individual second-generation antipsychotic drugs (olanzapine, risperidone clozapine compared with unexposed individuals: low to moderate rate ratio between 1.17 and 1.57; ziprasidone and sertindol: two or more times increased rate ratio; amisulpride, quetiapine and aripiprazole: no significantly increased rate ratio). For both first- and second-generation antipsychotics, the incidence of diabetes increased with the number of prescriptions. Additionally, the incidence of diabetes increased with the number of combined antipsychotic drugs.

CONCLUSIONS

In clinical practice, treatment with first- and second-generation antipsychotics is associated with an increased risk of developing incident diabetes with large differences between individual drugs. The risk increases with the duration of treatment and with polypharmacy of antipsychotic drugs.

Sources of patients' knowledge of the adverse effects of psychotropic medication and the perceived influence of adverse effects on compliance among service users attending community mental health services

BACKGROUND

Noncompliance with medication has been a complex issue with patients with severe mental illness during the last few decades, and adverse effects of medication have been identified as a major contributor to noncompliance.

OBJECTIVES

To assess the sources of patients' knowledge of the adverse effects of their prescribed medicines and the perceived effects of their knowledge and experiences of adverse effects on their compliance with prescribed medicines.

METHODS

A cross-sectional survey of 500 patients attending outpatient psychiatric services in an urban adult mental health services in Ireland was carried out to assess parameters relevant to the objectives of the study.

RESULTS

Of the 500 patients approached, 409 agreed to take part in the study, giving a response rate of 81.8%. Mean (SD) age was 41 (12) years, with 39% being males, and 74.9% having at least secondary education. Overall, 44% said they had learnt of adverse effects of their medication from multiple sources including physicians (52.31%), leaflets (54.2%), Internet (14.29%), books (13.02%), and chemist/pharmacist (11.34%). Of the patients, 46.2% reported that they have had concerns about taking their medication because of their knowledge of adverse effects, with females more likely to have such concerns than males. Moreover, 14.7% of patients reported that they had ever refused to take medication prescribed for them because of their knowledge of adverse effects, whereas 30.8% of patients reported that they had some time in the past stopped taking their medication because they had actually experienced adverse effects. Finally, when asked if they would have taken the medicines prescribed for them now if they were told initially of all the adverse effects, 50.60% answered "more likely," with a higher proportion of these being males.

CONCLUSIONS

Physicians and information leaflets are the leading sources of patients' knowledge about adverse effects of medication. The knowledge of adverse effects of medication has a potential to affect compliance, and so it is essential for physicians to engage patients in a fuller communication about their illness and its treatment with medication including the management of potential adverse effects.

Effects of olanzapine and ziprasidone on glucose tolerance in healthy volunteers

Atypical antipsychotics have been linked to a higher risk for glucose intolerance, and consequentially the development of type 2 diabetes mellitus (DM2). We have therefore set out to investigate the acute effects of oral administration of olanzapine and ziprasidone on whole body insulin sensitivity in healthy subjects. Using the standardized hyperinsulinemic euglycemic clamp technique we compared whole body insulin sensitivity of 29 healthy male volunteers after oral intake of either olanzapine 10 mg/day (n = 14) or ziprasidone 80 mg/day (n = 15) for 10 days. A significant decrease (p<0.001) in whole body insulin sensitivity from 5.7 ml/h/kg ( = mean, SM = 0.4 ml/h/kg) at baseline to 4.7 ml/h/kg ( = mean, SM = 0.3 ml/h/kg) after oral intake of olanzapine (10 mg/day) for 10 days was observed. The ziprasidone (80 mg/day) group did not show any significant difference (5.2+/-0.3 ml/h/kg baseline vs 5.1+/-0.3 ml/h/kg) after 10 days of oral intake. Our main finding demonstrates that oral administration of olanzapine but not ziprasidone leads to a decrease in whole body insulin sensitivity in response to a hyperinsulinemic euglycemic challenge. Our finding is suggestive that not all atypical antipsychotics cause acute direct effects on glucose disposal and that accurate determination of side effect profile should be performed when choosing an atypical antipsychotic.

Type 2 diabetes among persons with schizophrenia and other psychotic disorders in a general population survey

Schizophrenia and other psychotic disorders are associated with increased risk of developing type 2 diabetes. However, previous studies are mainly based on clinical samples where the comorbidity may be stronger. We investigated in a general population survey the prevalence of type 2 diabetes in persons with psychotic disorders and in users of antipsychotic medication. The study was based on a nationally representative two-stage cluster sample of 8,028 persons aged 30 or over from Finland. Diagnostic assessment of psychotic disorders combined SCID-I interview and case note data. Prevalences of type 2 diabetes, adjusting for age and sex, were estimated by calculating predicted marginals. The prevalence estimate of type 2 diabetes was 22.0% among subjects with schizophrenia, 13.4% among subjects with other nonaffective psychosis and 6.1% in subjects without psychotic disorders. Only two subjects (3.4%) with affective psychosis had type 2 diabetes. Users of all types of antipsychotic medication had increased prevalence of type 2 diabetes. Our results suggest that type 2 diabetes is a major health concern among persons with schizophrenia and other nonaffective psychotic disorders and also in users of antipsychotic medication, but persons with affective psychosis in the general population may not have increased prevalence of type 2 diabetes.

Effects of psychotropics on glycosylated hemoglobin (HbA1c) in a cohort of bipolar patients

OBJECTIVES

Research suggests that certain psychotropics may induce glucose regulatory dysfunction. Hyperglycemia increases levels of glycosylated hemoglobin (HbA1c). This study investigated the relationship between psychotropic use and concentrations of HbA1c in bipolar patients who were presumably non-diabetic.

METHODS

Analysis was conducted on 76,671 patients with bipolar disorder (BPD) from the Integrated Health Care Information Services (IHCIS). Included were 381 patients with at least two measurements of HbA1c taken between January 1, 1997 and June 30, 2002. Individuals with only 1 HbA1c measure, diagnosed with type 1 or type 2 diabetes according to the International Classification of Diseases (ICD-9), and/or who were using any anti-diabetes medication were excluded from the cohort. We compared HbA1c levels from first to final HbA1c measurements. The types of psychotropic medications used by the patients were examined.

RESULTS

A total of 197 (51.9%) BPD patients had an abnormal initial HbA1c test result (defined as HbA1c>7). Thirty patients were taking antipsychotics, 24 mood stabilizers (anticonvulsants), 10 lithium, 51 antidepressants and 116 a combination of medications. A total of 150 patients were not taking psychotropic medications. HbA1c levels declined significantly in patients taking psychotropic medication(s) [mean=7.5, standard deviation (SD)=2.1% versus mean=7.0, SD=1.8%; p<0.001] and in patients not taking psychotropic medication(s) (mean=7.4, SD=2.0% versus mean=7.0, SD=1.9%; p<0.001). The only exception to this finding was among patients taking antipsychotics, where there was a slight increase (not statistically significant) during this period (mean=7.0, SD=1.8% versus mean=7.2, SD=3.7%; p=0.791).

CONCLUSIONS

These results support findings suggesting an increased risk of type 2 diabetes in BPD patients. Mood stabilizers (anticonvulsants), antidepressants and lithium in monotherapy and combination were associated with a decrease in HbA1c levels. Although not statistically significant, antipsychotic medications were associated with an increase in HbA1c in this population.

Troubles métaboliques associés aux antipsychotiques atypiques : consensus belge sur la conduite à tenir

BACKGROUND

The current literature supports that schizophrenia (and bipolar disorders) appear to be associated with a higher prevalence of type 2 diabetes. Because of the silent nature of diabetes mellitus, and the fact that schizophrenic patients are not screened comprehensively for the disease, the true prevalence of hyperglycemia and diabetes may be substantially underestimated. Notably, it has been suggested that schizophrenia as such carries an increased risk, as certain characteristics of schizophrenic patients such as unhealthy life style promote the diabetes risk.

LITERATURE FINDINGS

This risk may be increased by antipsychotic drug treatment, as was already suggested for first-generation antipsychotics (FGA). The amount of literature on the association of SGA and metabolic disorders is much larger however, although well-controlled prospective data are sparse. Reports comprise abnormal glucose regulation, exacerbation of existing type 1 and 2 diabetes, new-onset pseudo-type 1 or type 2 diabetes, diabetic ketoacidosis, coma and death. In large-scale studies (mostly retrospective), reviews and meta-analyses, the association was not found for all drugs.

NEW DATA

According to recent reviews, the risk of developing diabetes was highest for clozapine and olanzapine, followed by quetiapine and risperidone. The hierarchy of liability of weight gain, or differential effects on insulin resistance was also in the described order. Apart from disturbances in glucose metabolism, further frequent metabolic abnormalities in schizophrenic patients on SGA include features of the metabolic syndrome. Antipsychotics such as clozapine and olanzapine have also been associated with hypertriglyceridemia, while agents such as haloperidol, risperidone and ziprasidone were associated with reductions in plasma triglycerides. Amisulpride, aripiprazole and ziprasidone seem to carry the lowest risk for weight gain, diabetes and effects on insulin resistance.

CONCLUSION

As a consequence, there is a shift in attention toward physical health monitoring in patients with mental health disorders. The APA and ADA as well a British working group have recently published the findings on SGA and metabolic abnormalities in a joint statement (table I).

Antipsychotic drugs and diabetes--an application of the Austin Bradford Hill criteria

There is concern that antipsychotic drugs cause diabetes. Although there has been an explosion in the quantity of literature about this subject, it remains confusing and inconsistent. To assess whether the association between antipsychotic drugs and diabetes is causative, we applied the Austin Bradford Hill criteria to the available evidence. In support of a causative relationship, there is temporality for some cases of diabetes, and there is a biologically plausible explanation. The causative link between antipsychotic drugs and diabetes is coherent with our understanding of diabetes and there are other analogies. However the strength of association is weak, there is lack of consistency or specificity, and there is little evidence to support a biological gradient. We should therefore conclude that the evidence surrounding a causative link between antipsychotic drugs and diabetes is inconclusive. Moreover, the risk is probably low and the attributable risk of developing diabetes is greater for traditional risk factors such as family history, ethnicity, obesity and ageing than it is for receiving an antipsychotic drug. Consequently, the majority of patients receiving second-generation antipsychotics will not develop diabetes as a result of their medication.

Metabolic risk factor profile associated with use of second generation antipsychotics: a cross sectional study in a Community Mental Health Centre

BACKGROUND

Second generation antipsychotics (SGA) have demonstrated several advantages over first generation antipsychotics (FGA) in terms of positive, negative, cognitive, and affective symptoms and a lower propensity for extrapyramidal side effects. Despite these undeniable advantages, SGA have been associated with causing and exacerbating metabolic disorders, such as obesity, diabetes, and hyperlipidemia. This cross sectional study aimed to evaluate the metabolic risk factor profile associated with use of SGAs in comparison with non -treated control patients.

METHODS

The study was carried out at a Community Mental Health Centre (CMHC) in Bologna. The study subjects were outpatients with serious mental disorders treated with SGA (clozapine, olanzapine, risperidone, quetiapine). A sample of adult men and women suffering from idiopathic hyperhydrosis, without psychiatric history or antipsychotic treatment, were randomly selected from outpatients of the Department of Neurology in Bologna as a reference group. We investigated differences among the treatment and reference groups for glycaemia, cholesterolaemia and triglyceridaemia levels.

RESULTS

The study sample was composed of 76 patients, 38 males and 38 females. The reference group was composed of 36 subjects, 19 females and 17 males. All patients treated with SGAs had higher mean glycaemia and triglyceridaemia and a significantly higher risk of receiving a diagnosis of hyperglycaemia and hypertriglyceridaemia than the reference group. We did not find any differences in mean glycaemia or mean triglyceridaemia levels among treatment groups. Patients with clozapine had a significantly higher mean BMI value and rate of obesity than patients treated with other SGAs.

CONCLUSION

The rate of obesity and metabolic disorders observed in this study were higher than the prevalence in the control group and similar to that previously reported in psychiatric samples; these findings imply per se that more attention should be paid to the metabolic condition of psychiatric patients. In line with the International Consensus Conferences we recommend that monitoring of weight, fasting plasma glucose, cholesterol and triglyceride levels be obtained in routine clinical practice with all antipsychotics.

Assessment of antipsychotic-related risk of diabetes mellitus in a Medicaid psychosis population: Sensitivity to study design

PURPOSE

The effect of study design on findings regarding diabetes risk associated with antipsychotics was studied.

METHODS

This study was a retrospective analysis of data from more than 100,000 Medicaid patients. Diabetes odds ratios (ORs) for patients treated with clozapine, olanzapine, quetiapine, risperidone, ziprasidone, or conventional antipsychotics versus untreated patients were estimated with and without the following design enhancements: screening for preexisting diabetes, selecting for antipsychotic monotherapy, and identifying diabetes with prescription claims only. Logistic regression controlled for patient sex, race and ethnicity, type of psychosis, length of observation and treatment, antipsychotic dosage, pre-existing excess weight or dyslipidemia, and use of other drugs with potential diabetogenic effects.

RESULTS

Under the weakest study design (none of the above enhancements), all antipsychotics were associated with significantly higher odds of diabetes relative to no treatment (p < 0.05). Estimated ORs were as follows: clozapine, 1.468; olanzapine, 1.108; quetiapine, 1.270; ziprasidone, 1.226; risperidone, 1.232; and conventional antipsychotics, 1.159. Under the strongest design (all of the above enhancements), ORs relative to no treatment were significant for clozapine (1.484) and olanzapine (1.149) and nonsignificant for quetiapine (0.998), risperidone (1.124), ziprasidone (0.717), and conventional antipsychotics (1.025). The data also strongly suggest selection bias by clinicians (i.e., selecting antipsychotics based on preexisting diabetes or risk factors for diabetes), disfavoring risperidone and favoring olanzapine. Although the evidence is weaker, quetiapine may also have been affected by unfavorable selection bias.

CONCLUSION

In large database studies, estimated risks of diabetes among patients treated with antipsychotics appeared to be influenced by study design. When a more rigorous design was used, only clozapine and olanzapine were associated with diabetes risk significantly greater than that in untreated patients.

Trends in Prescribing of Antipsychotic Medications for US Children

OBJECTIVE

To identify frequencies of prescribing for antipsychotics among all US children.

METHODS

Data were drawn from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, which are national samples of health care services rendered to the US population. Survey data were used to determine antipsychotic prescription frequencies for 2-18 year old US children from 1995-2002.

RESULTS

During 1995-2002, there were 5 762 193 visits to health providers by US children during which an antipsychotic was prescribed. Almost one third (32.4%) of the prescriptions were associated with visits to nonmental health providers. Fifty-three percent of the prescriptions were for behavioral indications or affective disorders, conditions for which antipsychotics have not been carefully studied in children. The overall frequency of antipsychotic prescribing increased from 8.6 per 1000 US children in 1995-1996 to 39.4 per 1000 US children in 2001-2002 (rate ratio 4.89, 95% CI, 2.50-9.55). Across all age groups, increases for nonstudied indications were even more pronounced than increases for approved indications.

CONCLUSION

The increase in frequencies of antipsychotic prescribing and the large number of children receiving antipsychotics each year reinforce the urgent need to conduct well-controlled studies of these medications in children.

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.

Belgian consensus on metabolic problems associated with atypical antipsychotics

A workshop was convened by a panel of psychiatrists, diabetologists and pharmacists from major Belgian hospitals to review the latest information relating to the risks with second-generation antipsychotics (SGA) for the development of metabolic disorders, especially impaired glucose tolerance, diabetes mellitus and dyslipidemia. The panelists sought to formulate recommendations for practising psychiatrists when initiating and maintaining therapy with SGA, and for the switch of SGA or initiation of further treatment if metabolic complications occur. In addition, recommendations for counselling of the patient and for the cooperation between the psychiatrist and the general physician or diabetologist, respectively, were provided.

Atypical antipsychotics and glucose dysregulation: a systematic review

Atypical antipsychotics (AAP) have been widely used for the management of patients with schizophrenia and other psychotic disorders since they were introduced during the past decade. AAP, as a class, have demonstrated a significant advantage over conventional antipsychotics in clinical efficacy and lower incidence of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). However, there have been numerous case reports, retrospective studies, epidemiological and clinical data suggesting that certain AAP may be associated with a greater risk of metabolic abnormalities than others, including weight gain, hyperlipidemia, and new-onset type 2 diabetes mellitus (DM) or diabetic ketoacidosis (DKA). In this article, we review and evaluate recent findings addressing the issue of glucose dysregulation associated with AAP therapy along with the recommendations with a recent consensus conference on this issue. Rational patient monitoring guidelines are also elucidated, particularly for high-risk populations that need more intensive scrutiny during treatment of AAP.

Quetiapine-induced diabetes with metabolic acidosis

Medication adherence with antipsychotics is adversely impacted by the burden of untoward adverse effects. In particular, sexual side-effects may interfere with compliance, but are often underreported by patients. Sexual dysfunction related to hyperprolactinemia is commonly described, but ejaculatory disturbance due to potent alpha1 adrenergic antagonism may also occur, and has been reported frequently with certain typical antipsychotics such as thioridazine, but rarely with atypical antipsychotics. Presented here is the case of a 51 year old male with schizophrenia who developed retrograde ejaculation on high dose risperidone therapy (8 mg/day) with prompt resolution of symptoms upon dose reduction. The absence of decreased libido or erectile dysfunction indicates that alpha1 adrenergic antagonism and not low serum testosterone due to hyperprolactinemia is the etiology for this side-effect. This case illustrates another mechanism for sexual adverse effects, and the need for routine inquiry into sexual dysfunction during atypical antipsychotic therapy.

Safety and tolerability of atypical antipsychotics in patients with bipolar disorder: prevalence, monitoring and management

Atypical antipsychotics are associated with fewer movement disorders and a lower risk of tardive dyskinesia than conventional antipsychotics, but are not without side-effects. Metabolic side-effects associated with some of the atypical antipsychotics are a concern for both clinicians and patients. Adverse events related to central nervous system effects, weight gain, and alterations in glucose, lipid, and prolactin levels in patients with depression, bipolar, and anxiety disorders have been reported. Balancing the significant benefits of treatment with these agents against the potential risks of metabolic disturbances and other adverse effects is crucial. Emerging data are making it possible to determine the risk-benefit analysis for specific atypical antipsychotics in individual patients and allow for targeted selection of treatment. A new concept of effectiveness is emerging that attempts to balance adverse effects of treatment with patient quality of life. Patients treated with atypical antipsychotics should have their weight, waist circumference, glucose, and lipids monitored on a regular basis. Monitoring of prolactin levels is not suggested; however, a baseline measurement before initiating treatment can be useful, with subsequent assessment only if a patient demonstrates symptoms. Prevention of weight gain is important. Diet and exercise should be considered for prevention and management, with the use of pharmacologic strategies approached with caution in patients with mood disorders. If a patient is at high risk of developing diabetes, certain pharmacologic agents have been shown to delay the onset of overt diabetes. Once diabetes or dyslipidemia are diagnosed, management should proceed in accordance with approved guidelines for these conditions.

Relationship of Atypical Antipsychotics with Development of Diabetes Mellitus

OBJECTIVE

To review the pharmacoepidemiologic evidence for the link between exposure to atypical antipsychotics and the development of diabetes mellitus.

DATA SOURCES

A MEDLINE search (1990-March 2003) was conducted.

STUDY SELECTION AND DATA EXTRACTION

The search was limited to articles that described findings from analyses of large databases and used the words diabetes or hyperglycemia, and antipsychotic or clozapine or olanzapine or risperidone or quetiapine or ziprasidone or aripiprazole in the title or abstract. The odds ratio or relative risk, together with their corresponding confidence interval, was extracted.

DATA SYNTHESIS

Results are conflicting, and this variability may be due to the different populations studied, different study designs, and the possibility of publication bias related to funding by the pharmaceutical industry. Nevertheless, an increased risk for diabetes mellitus appears to be present for patients receiving atypical antipsychotics. However, differential risk among the atypical antipsychotics is difficult to ascertain.

CONCLUSIONS

Clinicians are urged to manage risk by regularly monitoring all patients receiving atypical antipsychotics for the emergence of diabetes mellitus. Future studies should carefully control for confounding variables such as age, diagnosis, change in weight, activity level, family history, and ethnicity.