Retrospective Cohort Study of Diabetes Mellitus and Antipsychotic Treatment in a Geriatric Population in the United States

Risperidone in the management of agitation and aggression associated with psychiatric disorders

Objective

This review provides an overview of the prevalence and treatment of agitation and aggression, and focuses on the use of risperidone to treat these symptoms in patients from different age groups.

Methods

MEDLINE® and EMBASE® databases were used to identify controlled studies of risperidone in the treatment of disruptive behavior disorders and pervasive developmental disorders in pediatric patients, acute agitation or aggression in adults, and psychological and behavioral symptoms of dementia in the elderly. Additionally, key open-label, long-term trials assessing the efficacy and safety of risperidone were considered.

Results

The results of the 19 double-blind studies identified showed that risperidone is effective in treating agitation and aggression in the different populations, regardless of age. The safety and tolerability of risperidone appear to be good overall but certain safety issues, such as a higher risk of cerebrovascular adverse events in the elderly with dementia, were highlighted.

Conclusions

Risperidone is useful for treating aggression and agitation associated with various psychiatric disorders in patients from different age groups.

Metabolic side effects of atypical antipsychotics in older adults

ABSTRACTBackground:The atypical antipsychotics (AAPs) are associated with a recognized class effect of glucose and lipid dysregulation. The use of these medications is rapidly increasing in elderly patients with, and without, dementia. However, the metabolic risks specific to elderly remain poorly studied.

METHODS

Design: A case-control study.

SETTING

Psychogeriatric service in Auckland, New Zealand.

PARTICIPANTS

Elderly patients either receiving AAP treatment (cases) or not (controls) between 1 Jan 2008 and 1 Jan 2014.

MAIN OUTCOME MEASURES

metabolic data of glucose, HbA1c, lipids, and cardiovascular events and death. The data were analyzed using t-tests and linear regression models for each metabolic outcome.

RESULTS

There were 330 eligible cases and 301 controls from a total study population of 5,307. There was a statistically significant change in the HbA1c over time, within the cases group of -1.14 mmol/mol (p = 0.018, 95% CI -0.19 to -2.09). Also statistically significant was the reduction in total cholesterol of -0.13 mmol/L (p = 0.036, 95% CI -0.008 to -0.245). The only significant difference found between cases and controls was in the change in cholesterol ratio of 0.16 mmol/L between groups (95%CI 0.01-0.31, p = 0.036).

CONCLUSIONS

AAP use was not associated with any clinically significant change in metabolic outcomes in this study population.

Prophylactic Use of Haloperidol and Changes in Glucose Levels in Hospitalized Older Patients

BACKGROUND

Treatment with antipsychotic drugs has been associated with glucose dysregulation in older outpatients, especially in the early stage of therapy. The underlying mechanism is, however, unclear. The aim of this study was to investigate changes in glucose levels during haloperidol use compared with the use of placebo among older hospitalized patients.

METHODS

This substudy was part of a larger multicenter, randomized, double blind, placebo-controlled clinical trial among hospitalized patients aged 70 years and older who had an increased risk of in-hospital delirium. Patients who were admitted to the Jeroen Bosch Hospital in 's-Hertogenbosch between June 2014 and February 2015 were invited to participate in the study. Participating patients were randomized for treatment and given 1 mg of haloperidol or a placebo twice daily for a maximum of 7 consecutive days (14 doses). Exclusion criteria for this substudy were the use of corticosteroids and changes in diabetes medication. Random blood samples to determine glucose levels were collected before day 1 and on day 6 of the study. Student independent sample t test was used to determine differences in glucose changes between both groups.

RESULTS

Twenty-nine patients were included (haloperidol, n = 14; placebo, n = 15). The mean glucose level for placebo users was 139.3 mg/dL (SD, 50.1) on day 1 and 140.8 mg/dL (SD, 45.7) on day 6, and the mean glucose level for haloperidol users was 139.9 mg/dL (SD, 71.0) on day 1 and 150.2 mg/dL (SD, 39.1) on day 6. The difference was not statistically significant (P = 0.685).

CONCLUSIONS

Short-term prophylactic use of haloperidol was not associated with changes in glucose levels in older hospitalized patients compared with those given a placebo in this small study.

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.

Real-world risk of diabetes with antipsychotic use in older New Zealanders: a case-crossover study

PURPOSE

The primary aim was to examine and compare the increased risk of incident diabetes associated with second-generation antipsychotics (SGAs) and first-generation antipsychotics (FGAs), with and without adjusting for potential confounding factors. The secondary aim was to recalculate the relative risks of diabetes onset using a semi-symmetric bidirectional case-crossover (SSBC) design to adjust for time-trend bias.

METHOD

Prescription records (2005-2015) of antipsychotics were sourced from New Zealand Pharmaceutical Collections. The first-time diabetes diagnosis was extracted from the National Minimal Dataset. Relative risks (RRs) of diabetes onset were calculated using conditional logistic regression. Time-trend bias was corrected by recalculating the RR using a SSBC design.

RESULTS

Among 645 individuals, the risk of diabetes onset is higher in SGA users (ARR = 8.72, 95% CI = [5.57, 13.67]) compared to FGA users (ARR = 5.68, 95% CI = [3.43, 9.39]). The increased risk of diabetes onset associated with quetiapine is higher (ARR = 7.47, 95% CI = [4.10, 13.62]), compared to haloperidol (ARR = 5.05, 95% CI = [2.91, 8.75]). However, the increased risk of diabetes onset associated with olanzapine (ARR = 2.27, 95% CI = [0.86, 5.98]) is insignificant after adjusting for concomitant use of effect modifiers and other antipsychotic drugs.

CONCLUSION

The results support that the magnitude of the risk of diabetes is higher with SGA use compared with FGA use, and the risk is higher when co-prescribed. Confounding by indication and time-varying confounders such as body mass index could bias the risk of onset of diabetes. Marginal structural models could provide more precise estimates of the risk of onset of diabetes following exposure to antipsychotics.

Risk of Hospitalization for Hypoglycemia in Older Patients with Diabetes Using Antipsychotic Drugs

OBJECTIVE

Antipsychotics may disrupt metabolic regulation in patients with diabetes mellitus. The risk of hypoglycemia in older users of antipsychotics with diabetes is largely unknown. Therefore, we investigated the association between the use of antipsychotic drugs and hypoglycemia requiring hospital admission in older patients with diabetes.

METHODS

In a nested case-control study using community pharmacy records linked to hospital admission data in the Netherlands (1998-2008), a cohort of 68,314 patients at least 65 years with diabetes was studied. Cases were patients from the study cohort with a first hospital admission for hypoglycemia; up to five comparison subjects were selected for each case. Exposure to antipsychotic drugs was the primary determinant of interest. Logistic regression analysis was performed to estimate the strength of the association between antipsychotic drug use and hypoglycemia, taking into account potential confounders.

RESULTS

Eight hundred fifteen patients were admitted to hospital for hypoglycemia. Current use of antipsychotic drugs was associated with an increased risk of hypoglycemia compared with non-use (adjusted OR: 2.26; 95% CI: 1.45-3.52; Wald χ(2) = 13.08, df = 1, p ≤0.001), especially in the first 30 days of treatment (adjusted OR: 7.65; 95% CI: 2.50-23.41; Wald χ(2) = 12.72, df = 1, p ≤0.001) and with higher doses (adjusted OR: 8.20; 95% CI: 3.09-21.75; Wald χ(2) = 17.90, df = 1, p ≤0.001).

CONCLUSION

Use of antipsychotic drugs by older patients with diabetes mellitus was associated with an increased risk of hospitalization for hypoglycemia. Our findings suggest that glucose levels should be monitored closely after initiation of antipsychotic drugs.

Effect of Psychotropic Drugs on Development of Diabetes Mellitus in Patients With Alzheimer's Disease

We aimed to examine risk of diabetes mellitus (DM) among older adults with Alzheimer's disease receiving 3 types of psychotropic drugs, that is, antipsychotics, antidepressants, and sedative anxiolytics. We retrospectively analyzed data from a hospital-based Clinical Research Center for Dementia of South Korea (CREDOS) study conducted between January 1, 2008 and December 31, 2012. Participants (n = 3042) with Alzheimer's disease were aged 65 or older and had no preexisting history of DM. Development of DM was identified using claims for initiating at least 1 prescription of antidiabetic medications or a diagnosis of DM during the follow-up period. Cox proportional hazards regression was used to demonstrate the Hazard ratio of DM in use of each psychotropic drug. Among the 3042 participants, 426 patients (14.0%) developed DM, representing an incidence rate of 5.2/100 person-years during an average 2.9 years of follow-up period. Among the 3 types of psychotropic drugs, antipsychotic users had a significantly higher risk of DM (hazard ratio = 1.74, 95% confidence interval = 1.10, 2.76) than nonusers, after adjusting covariates. Antidepressants and sedative anxiolytics did not achieve statistical significance. These results suggested that the diabetes risk was elevated in Alzheimer patients on antipsychotic treatment. Therefore, patients with Alzheimer's disease receiving antipsychotic treatment should be carefully monitored for the development of DM.

Atypical antipsychotic-induced metabolic disturbances in the elderly

The metabolic side effects of atypical antipsychotics (AAPs) have been widely studied in younger populations, but research investigating these sequelae in the elderly is lacking. This article reviews the available literature examining the use of AAPs in the elderly, evaluating their association with weight gain and changes in blood glucose and lipid parameters. We find a relative paucity of studies in this area; while some data highlight significant, collective changes in metabolic parameters, the majority suggests an apparent low vulnerability to these side effects. We conclude that the risk and clinical implications of unfavorable metabolic changes in the elderly being treated with AAP medications remain largely undetermined, and we caution against drawing firm conclusions based on the available data. The conflicting evidence leaves us recommending that metabolic monitoring be implemented, with regular follow-up as advocated in other populations.

Misclassification in assessment of diabetogenic risk using electronic health records

PURPOSE

Suspected diabetogenic effects or drug indication may increase testing for diabetes mellitus (DM), resulting in measurement bias when evaluating diabetogenic drug effects. We sought to evaluate the validity of electronic health record data in determining DM risk.

METHODS

We used time-dependent Cox proportional hazard models within a retrospective cohort design to assess associations between use of antihypertensives, statins, atypical antipsychotics, and antidepressants, and two endpoints: (i) DM onset defined as fasting blood glucose (BG) ≥126 mg/dl, random BG ≥200 mg/dl, HbA1c ≥7.0%, or antidiabetic drug initiation; and (ii) first negative DM test. We used Poisson regression to assess the influence of these drugs on DM testing rates. Patients aged 35-64 years enrolled in Kaiser Permanente Northwest between 1997 and 2010 entered the cohort at the first negative BG test after ≥6 months without manifest DM.

RESULTS

All drug classes showed significant associations not only with DM onset but also with first negative BG test and with DM testing rates. Antipsychotics had the greatest diabetogenic risk (adjusted hazard ratio [HR] = 1.73 [1.44-2.08]), the greatest propensity for a first negative test (adjusted HR = 1.87 [1.74-2.01]), and the highest testing rate (adjusted rate ratio = 1.76 [1.72-1.81]. Although renin-angiotensin system blockers and calcium channel blockers have shown no diabetogenic risk in clinical trials, both were associated with DM (HR = 1.19 [1.12-1.26] and 1.27 [1.17-1.38]), a negative glucose test (1.38 [1.35-1.41] and 1.24 [1.20-1.28]), and increased testing rates (rate ratio = 1.26 [1.24-1.27] and 1.27 [1.25-1.28]).

CONCLUSION

Caution should be used when diabetogenic risk is evaluated using data that rely on DM testing in general practice.

A systematic review of metabolic side effects related to the use of antipsychotic drugs in dementia

BACKGROUND

In clinical practice, Second Generation Antipsychotics (SGAs) are often used as first-line treatment for the Behavioral and Psychological Symptoms of Dementia (BPSD) in older adults due to their fewer neurological adverse events and similar effectiveness compared with First Generation Antipsychotics (FGAs). SGAs, however, are associated with more severe metabolic side effects (weight gain, hyperglycemia, diabetes risk, and hyperlipidemia) than FGAs are. In general, older patients, especially those affected by dementia, are at increased risk for malnutrition, and tend to have lower basal metabolism and reduced liver and kidney function. However, little is known about the metabolic side effects of antipsychotic drugs in this population.

METHODS

A comprehensive review of the literature published between January 1996 and December 2012 investigating the metabolic side effects related to FGAs and SGAs use in old patients affected by dementia.

RESULTS

Antipsychotic drugs currently used to treat BPSD in subjects with mild to moderate dementia are associated with weight gain. Currently, there are insufficient data to support a causal relationship between the use of FGAs and SGAs and changes in glucose homeostasis or lipid metabolism in older persons affected by severe dementia (MMSE <14).

CONCLUSION

A possible association between antipsychotic drugs use and weight gain might exist, in particular in subjects with mild to moderate dementia whereas no significant effects are demonstrated regarding glucose homeostasis and lipid metabolism. The antipsychotic drugs potential for causing metabolic abnormalities in older patients requires further specifically designed studies. Clinicians must be aware of this possibility even if the shorter periods of treatment administered in late-life might not be as harmful as it is in younger individuals.

Association between second-generation antipsychotics and newly diagnosed treated diabetes mellitus: does the effect differ by dose?

BACKGROUND

The benefits of some second-generation antipsychotics (SGAs) must be weighed against the increased risk for diabetes mellitus. This study examines whether the association between SGAs and diabetes differs by dose.

METHODS

Patients were ≥18 years of age from three US healthcare systems and exposed to an SGA for ≥45 days between November 1, 2002 and March 31, 2005. Patients had no evidence of diabetes before index date and no previous antipsychotic prescription filled within 3 months before index date.49,946 patients were exposed to SGAs during the study period. Person-time exposed to antipsychotic dose (categorized by tertiles for each drug) was calculated. Newly treated diabetes was identified using pharmacy data to determine patients exposed to anti-diabetic therapies. Adjusted hazard ratios for diabetes across dose tertiles of SGA were calculated using the lowest dose tertile as reference.

RESULTS

Olanzapine exhibited a dose-dependent relationship for risk for diabetes, with elevated and progressive risk across intermediate (diabetes rate per 100 person-years = 1.9; adjusted Hazard Ratio (HR), 1.7, 95% confidence interval (CI), 1.0-3.1) and top tertile doses (diabetes rate per 100 person-years = 2.7; adjusted HR, 2.5, 95% CI, 1.4-4.5). Quetiapine and risperidone exhibited elevated risk at top dose tertile with no evidence of increased risk at intermediate dose tertile. Unlike olanzapine, quetiapine, and risperidone, neither aripiprazole nor ziprasidone were associated with risk of diabetes at any dose tertile.

CONCLUSIONS

In this large multi-site epidemiologic study, within each drug-specific stratum, the risk of diabetes for persons exposed to olanzapine, risperidone, and quetiapine was dose-dependent and elevated at therapeutic doses. In contrast, in aripiprazole-specific and ziprasidone-specific stratum, these newer agents were not associated with an increased risk of diabetes and dose-dependent relationships were not apparent. Although, these estimates should be interpreted with caution as they are imprecise due to small numbers.

Antipsychotic drugs and the risk of hyperglycemia in older adults without diabetes: a population-based observational study

OBJECTIVE

To determine whether current antipsychotic use among older persons without diabetes is associated with a higher risk of hospital visits for hyperglycemia, as previous studies in this population have yielded conflicting results.

DESIGN, SETTING AND PARTICIPANTS

A nested case-control study within a population-based cohort of persons aged 66 years or older without diabetes, who initiated antipsychotic therapy between April 1, 2002, and March 31, 2006. Cohort members were identified using health databases from Ontario, Canada, and were followed from treatment start until March 31, 2007.

MEASUREMENTS

Cases were patients with a hospital visit (emergency department visit or hospital admission) for hyperglycemia. We matched each case with up to 10 controls. We compared the risk of hyperglycemia among current antipsychotic users to that of remote users (discontinued > 180 days).

RESULTS

The cohort consisted of 44,121 subjects, mean age of 78.3 years, followed for a mean of 2.2 years. Compared to remote antipsychotic use, current treatment with any antipsychotic was associated with a significantly increased risk of hospital visits for hyperglycemia (adjusted odds ratio [aOR]: 1.52; 95% confidence interval [CI]: 1.07-2.17). The risk was elevated for both atypical (aOR: 1.44; 95% CI: 1.01-2.07) and typical (aOR: 2.86; 95% CI: 1.46-5.59) antipsychotic agents.

CONCLUSIONS

Current use of either atypical or typical antipsychotic agents was associated with a significantly increased risk of hospital visits for hyperglycemia among older persons without diabetes. These findings highlight the need for close glucose monitoring during antipsychotic therapy in older populations.

The elderly safety imperative and antipsychotic usage

Behavioral and psychotic symptoms are common problems in older adults, and as the population ages, understanding the benefits and risks of antipsychotic usage is increasingly important. In this age group, psychotic symptoms may occur in patients with dementia or as part of schizophrenia, mood disorders, delirium, or delusional disorder. Various antipsychotics have been studied in older adults with psychotic symptoms, demonstrating mixed, but real, benefit, especially in relation to carefully selected patients. Caution is required because of the potential side effects and risks, which include increased mortality and cardiovascular and cerebrovascular events. This article reviews the use of antipsychotics in older adults, with emphasis on the risks and side effects, particularly in dementia patients with behavioral and psychotic symptoms.

The incidence of diabetes in atypical antipsychotic users differs according to agent--results from a multisite epidemiologic study

PURPOSE

The purpose of this study was to examine the association between atypical antipsychotics, including the newer agents, aripiprazole and ziprasidone, and newly treated diabetes, using the largest post-marketing cohort of patients exposed to these newer treatments that has been studied to date.

METHODS

Identified two overlapping cohorts-a simple cohort (all antipsychotic users) and an inception cohort (new users of antipsychotics)-using automated data from three United States sites (60.4 million covered lives). Patients exposed to antipsychotics > or = 45 days were identified and followed for incident diagnoses of treated diabetes. Data analysis accounted for drug switching and non-consistent drug use.

RESULTS

In the 55 287-member inception cohort, 357 cases of newly treated diabetes were identified. Compared with current use of typical antipsychotics, current users of aripiprazole (adjusted hazard ratio (aHR) 0.93, 95% confidence interval (CI) 0.50-1.76), quetiapine (aHR 1.04, 95%CI, 0.67-1.62), risperidone (aHR 0.85, 95%CI, 0.54-1.36) and ziprasidone (aHR 1.05, 95%CI, 0.54-2.08) had similar low risk of diabetes. Patients exposed to olanzapine had an increased risk of diabetes (aHR 1.71, 95%CI, 1.12-2.61), and although the effect estimate is imprecise, clozapine-exposed patients had a trend towards an elevated hazard ratio (aHR 2.58, 95%CI, 0.76-8.80). Results for the simple cohort were similar.

CONCLUSIONS

Relative to typical antipsychotics, aripiprazole, ziprasidone, risperidone and quetiapine were not associated with an increased risk of diabetes; olanzapine and clozapine were associated with an increased risk. This analysis constitutes the largest post-marketing pharmacoepidemiologic study to date that includes the newer agents.

Influence of medication choice and comorbid diabetes: the cost of bipolar disorder in a privately insured US population

BACKGROUND

Bipolar disorder is the most expensive mental disorder for US employer health plans. No published studies have examined the impact of comorbid diabetes on the cost of treating bipolar disorder. The objectives of this work were to determine the direct costs incurred by patients with bipolar disorder in a US managed care plan, and to examine the influence (1) of drug therapy regimen on bipolar-related costs, and (2) of diabetes on bipolar-related and all-cause costs.

METHODS

A retrospective analysis of claims in a US private insurance database from January 1, 1999 through December 31, 2002 was performed. The database included at least 4.7 million enrollees each year. Diagnosis codes were used to identify patients with bipolar disorder; patients with diabetes were identified using diagnosis codes and medication use.

RESULTS

From 1999-2002, treated bipolar disorder was identified in 262 (33.9) [mean (standard deviation)] cases per 100,000 enrollees. Among patients with bipolar disorder in this cohort, between 6.3 and 7.4% were treated for diabetes each year. Among patients with newly treated bipolar disorder, 61.8% received initial therapy with only mood stabilizers, 24.3% received only atypical antipsychotics, and 13.9% received both. Mean all-cause cost for patients with bipolar disorder was US$2,690 in the 6 months before the first bipolar-related claim, and US$6,826 in the following year. Of the latter cost, bipolar-related cost was US$1,272. Patients with comorbid diabetes had much higher all-cause cost (US$11,317) than those without diabetes in the year following the first bipolar-related claim, but only slightly higher bipolar-related cost (US$1,349). Among newly treated bipolar disorder patients, all-cause and bipolar-related cost in the year after diagnosis was lowest in patients receiving only mood stabilizers. Ordinary least squares regression analysis found that treatment with mood stabilizers only was associated with 41% lower bipolar-related cost than treatment with atypical antipsychotics only (P < .001). Significant individual associations were also found between bipolar-related cost and bipolar disorder I diagnosis, severe bipolar disorder and comorbid personality disorders (P < .001 for each) but not comorbid diabetes (P = .27).

CONCLUSIONS

These results suggest that patients with bipolar disorder who receive only mood stabilizer therapy incur lower bipolar-related and all-cause cost than those receiving only atypical antipsychotics. In contrast to that for all-cause cost, comorbid diabetes had little impact on direct costs related to treating bipolar disorder itself.

Distinct endocrine effects of chronic haloperidol or risperidone administration in male rats

Antipsychotic drugs have been used effectively for the treatment of schizophrenia symptoms, but they are often associated with metabolic side effects such as weight gain and endocrine disruptions. To investigate the possible mechanisms of antipsychotic-induced metabolic effects, we studied the impact of chronic administration of a typical antipsychotic drug (haloperidol) and an atypical antipsychotic (risperidone) to male rats on food intake, body weight, adiposity, and the circulating concentrations of hormones and metabolites that can influence energy homeostasis. Chronic (28days) haloperidol administration had no effect on food intake, weight gain or adiposity in male rats, whereas risperidone treatment resulted in a transient reduction in food intake and significantly reduced body weight gain compared to vehicle-treated control rats. Whereas neither antipsychotic had any effect on serum lipid profiles, glucose tolerance or the circulating concentrations of hormones controlled by the hypothalamo-pituitary-thyroid (free T4), -adrenal (corticosterone), -somatotropic (IGF-1), or -gonadotropic axes (testosterone), haloperidol increased circulating insulin levels and risperidone increased serum glucagon levels. This finding suggests that haloperidol or risperidone induce distinct metabolic effects. Since metabolic disorders such as obesity and type 2 diabetes mellitus represent serious health issues, understanding antipsychotic-induced endocrine and metabolic effects may ultimately allow better control of these side effects.

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.

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.

Retrospective analysis of diabetes risk in elderly patients with dementia in olanzapine clinical trials

OBJECTIVE

The objective of this study was to evaluate the association of established risk factors for treatment-emergent diabetes (TED) among patients over 65 years of age with dementia who received treatment with olanzapine.

METHODS

This was a post hoc analysis of data pooled from seven olanzapine clinical trials, which included patients over 65 years of age with dementia. The association of established risk factors for TED was evaluated using categorical and time-to-event analysis. TED was defined as two casual (fasting or nonfasting) glucose values > or =200 mg/dL at any time after baseline or one casual glucose value > or =200 mg/dL at the final visit, initiation of antidiabetic medication, or new clinical diagnosis of diabetes.

RESULTS

Elderly patients subsequently identified with TED (N = 29, 2.1%) had similar baseline body mass indices (24 kg/m(2)) and were similar in age (82 versus 80 years) to those who did not have TED. Cox proportional hazards model identified only elevated casual glucose (> or =140 mg/dL) measure at baseline to be significantly associated with the development of TED (hazard ratio [HR] = 11.2, p <0.0001) in this elderly cohort. Other clinical risk factors, like body mass index > or =25 (HR = 0.86), 7% weight gain (HR = 2.26), and antipsychotic treatment (HR = 1.36) were not significant.

CONCLUSION

In elderly patients with dementia enrolled in olanzapine clinical trials, an elevated casual glucose (> or =140 mg/dL) at baseline was the only risk factor significantly associated with subsequent development of TED. Risk of diabetes in these studies was not significantly associated with antipsychotic treatment group assignment.

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.

Incidence of new-onset diabetes mellitus among patients receiving atypical neuroleptics in the treatment of mental illness: evidence from a privately insured population

The purpose of this study is to determine sociodemographic, clinical, and pharmacotherapeutic characteristics, especially use of atypical antipsychotics, associated with incident diabetes mellitus in a population of privately insured patients with mental health diagnoses. Patients with a mental health diagnosis stably medicated for a 3-month period during January 1999 through October 2000 and having no diabetes were followed through December 2000. Cox proportional hazards models were developed to identify antipsychotic medications associated with newly diagnosed diabetes. Of the 7381 patients identified, 339 developed diabetes, representing an annual incidence rate of 4.7%. Diabetes risk among the entire sample was lowest for risperidone (hazard ratio [HR] = 0.69; p < 0.05), while quetiapine (HR = 0.74), olanzapine (HR = 0.95), and clozapine (HR = 1.22) were not significantly different from first-generation antipsychotics. Diabetes risk was significantly lower among males receiving risperidone (HR = 0.49; p < 0.01) or quetiapine (HR = 0.50; p < 0.10), while diabetes risk among females did not differ significantly from first-generation antipsychotics for any atypical examined. These findings are substantially different from other reports.

Treatment of behavioural and psychiatric symptoms in dementia: implications of recent safety warnings

Atypical antipsychotics are commonly used off-label to treat behavioural and psychiatric symptoms in dementia (BPSD), particularly in elderly care homes. Much of this use is inappropriate, and trials have shown an increased likelihood of serious cerebrovascular adverse events (CVAEs) such as stroke and transient ischemic attack (TIA) in elderly patients. The aetiology of this risk is not known, but may be related to metabolic effects and excess weight gain. Based on a review of published trials with risperidone and olanzapine that shows a three-fold increase in stroke risk in elderly patients with dementia, regulators in Europe and the USA now recommend against using these agents for behavioural control, particularly in patients with a history of cerebrovascular disease. When making prescribing decisions, physicians should pay careful attention to risk versus benefit with psychotropics. Antipsychotics should be regarded only as rescue medications for acute-onset (over hours or days) or for severe chronic BPSD, or used in patients who are aggressive and/or represent a danger to themselves or others. If atypical antipsychotics are prescribed, physicians should screen for risk factors for both stroke and cardiovascular disease when initiating treatment, and regular monitoring should be undertaken if patients with chronic behavioural problems receive antipsychotic maintenance therapy. International guidelines are now required that direct prescribers in the appropriate use of alternative therapies for BPSD. Cholinesterase inhibitors (ChEIs), particularly rivastigmine, can delay the onset and reduce the severity of neuropsychiatric symptoms in dementia, and decrease the requirement for antipsychotic and other psychotropic medications. Evidence suggests that they may be more appropriate for the control of chronic (over weeks to months) mild-to-moderate BPSD.