Diabetic ketoacidosis and severe hypertriglyceridaemia as a consequence of an atypical antipsychotic agent

Clozapine-induced Insulin-resistant Hyperglycemia in a Diabetic Patient

Clozapine is superior to all other antipsychotics in treatment-resistant schizophrenia. However, metabolic side effects are common while treating patients with clozapine. Administering clozapine in a patient who already is diabetic involves careful weighing of risks and benefits. Here, we report our experience of starting clozapine in a known diabetic patient. Clozapine was started in a patient with treatment-resistant psychosis in view of suicidal risk. Her diabetes mellitus was under good control with oral medications. After initiation of clozapine, blood sugars increased several fold within few days. Blood glucose continued to increase even with high doses of insulin and insulin infusion. Finally, blood sugars came under control only after discontinuation of clozapine. Precautionary measures while initiating clozapine in a diabetic patient are suggested - close monitoring of blood sugar during the initial few days and intensive intervention if blood sugar levels increase. Discontinuation of clozapine should also be kept in mind as a last resort.

Unresolved Issues for Utilization of Atypical Antipsychotics in Schizophrenia: Antipsychotic Polypharmacy and Metabolic Syndrome

Atypical antipsychotics (AAP) are the prevailing form of schizophrenia treatment today due to their low side effects and superior efficacy. Nevertheless, some issues still need to be addressed. First, there are still a large number of patients with treatment-resistant schizophrenia (TRS), which has led to a growing trend to resort to AAP polypharmacy with few side effects. Most clinical treatment guidelines recommend clozapine monotherapy in TRS, but around one third of schizophrenic patients fail to respond to clozapine. For these patients, with clozapine-resistant schizophrenia AAP polypharmacy is a common strategy with a continually growing evidence base. Second, AAP generally have great risks for developing metabolic syndrome, such as weight gain, abnormality in glucose, and lipid metabolism. These metabolic side effects have become huge stumbling blocks in today's schizophrenia treatment that aims to improve patients' quality of life as well as symptoms. The exact reasons why this particular syndrome occurs in patients treated with AAP is as yet unclear though factors such as interaction of AAP with neurotransmitter receptors, genetic pholymorphisms, type of AAPs, length of AAP use, and life style of schizophrenic patients that may contribute to its development. The present article aimed to review the evidence underlying these key issues and provide the most reasonable interpretations to expand the overall scope of antipsychotics usage.