Atypical antipsychotics and glycemia: a case report

A case report and literature review of olanzapine-associated hyperglycemia with previous history of gestational diabetes

Background

Olanzapine (Zyprexa) package labeling includes a warning for hyperglycemia, stating physicians should consider the risks and benefits when prescribing olanzapine to patients with an established diagnosis of diabetes mellitus or having borderline increased blood glucose levels. A case report of olanzapine-associated hyperglycemia in a patient with a history of gestational diabetes mellitus (GDM) is presented and literature review is discussed.

Case Report

A 33-year-old female with a past medical history of bipolar disorder, cocaine and amphetamine use disorder, hypertension, and GDM was initiated on olanzapine 5 mg PO daily which was subsequently titrated to 25 mg daily. On day 15 of admission, she developed signs and symptoms of hyperglycemia, with blood glucose readings >500 mg/dL. Insulin was initiated, olanzapine was discontinued, and her blood glucose began improving. She was later discharged on ziprasidone 20 mg PO twice daily.

Discussion

There have been several case reports published on olanzapine-induced hyperglycemia. This is the first case report to specifically recognize a history of GDM as a potential risk factor for developing olanzapine-associated hyperglycemia.

Conclusion

Adverse effect profiles and patient-specific risk factors should be considered when selecting appropriate antipsychotic treatment. Olanzapine may not be an ideal medication choice for a person with a history of GDM; however, if olanzapine is indicated, then close blood glucose monitoring is recommended.

Treatment of Diabetic Ketoacidosis Associated With Antipsychotic Medication: Literature Review

BACKGROUND

The second-generation antipsychotics (SGAs) are associated with metabolic disturbances. Diabetic ketoacidosis (DKA) is a rare, but potentially fatal sign of acute glucose metabolism dysregulation, which may be associated with the use of SGAs. This study aims to review published reports of patients with schizophrenia and antipsychotic drug-associated DKA, focusing on the effective management of both conditions.

METHODS

Using a predefined search strategy, we searched PubMed and EMBASE from their inception to July 2016. The search terms were related to "diabetic ketoacidosis" and "antipsychotic medication." Case reports, case series, and reviews of case series written in English language were included in the review.

RESULTS

Sixty-five reports were analyzed. In most patients who developed antipsychotic-associated DKA, 1 or more suspected antipsychotic medications were discontinued. In 5 cases, a rechallenge test was trialed, and in only 1 case, it resulted in the elevation of blood glucose. The majority was subsequently treated with a different SGA in combination with insulin/oral hypoglycemic agents; although approximately a third of patients had a complete resolution of symptoms or could control diabetes with diet only at the point of discharge.

CONCLUSIONS

Patients taking antipsychotic medications should be regularly screened for insulin resistance and educated about potential complications of antipsychotic medications. This will allow clinicians to individualize treatment decisions and reduce iatrogenic contribution to morbidity and mortality. To achieve best treatment outcomes, antipsychotic-induced DKA should be treated jointly by psychiatry and endocrinology teams.

Atypical antipsychotics and diabetic ketoacidosis: a review

RATIONALE

Atypical antipsychotics have been linked to weight gain and type 2 diabetes, but are also associated with diabetic ketoacidosis (DKA), which can occur more acutely and in the absence of weight gain.

OBJECTIVES

Our aim was to review current case reports of DKA in the context of atypical antipsychotic treatment to better understand (a) the scope of the problem, (b) its relationship to different atypical agents, (c) risk factors, (d) long-term outcome, and (e) putative mechanisms of action.

METHOD

Searches in PubMed/Medline, as well as the University of Toronto's Scholar Portal, were performed for all relevant articles/abstracts in English.

RESULTS

Sixty reports, yielding 69 cases, affirm that DKA is a rare but serious risk with almost all atypical antipsychotics; however, liability seems to vary between agents, at least partially mirroring risk of weight gain. Mean age of onset was 36.9 years (range 12-80), with 68 % of cases occurring in males, and 41 % in individuals of African American or African Caribbean descent. Over one third of cases present with either no weight gain or weight loss, and 61 % of these require ongoing treatment for glycemic control. Death occurred in 7.25 % of cases.

CONCLUSION

While the underlying mechanisms are not well understood, antipsychotic-related DKA can occur soon after treatment onset and in the absence of weight gain. Although rare, clinicians must remain vigilant given its acute onset and potential lethality.

Effective lifestyle interventions to improve type II diabetes self-management for those with schizophrenia or schizoaffective disorder: a systematic review

BACKGROUND

The prevalence of type II diabetes among individuals suffering from schizophrenia or schizoaffective disorders is more than double that of the general population. By 2005, North American professional medical associations of Psychiatry, Diabetes, and Endocrinology responded by recommending continuous metabolic monitoring for this population to control complications from obesity and diabetes. However, these recommendations do not identify the types of effective treatment for people with schizophrenia who have type II diabetes. To fill this gap, this systematic evidence review identifies effective lifestyle interventions that enhance quality care in individuals who are suffering from type II diabetes and schizophrenia or other schizoaffective disorders.

METHODS

A systematic search from Medline, CINAHL, PsycINFO, and ISI Web of Science was conducted. Of the 1810 unique papers that were retrieved, four met the inclusion/exclusion criteria and were analyzed.

RESULTS

The results indicate that diabetes education is effective when it incorporates diet and exercise components, while using a design that addresses challenges such as cognition, motivation, and weight gain that may result from antipsychotics.

CONCLUSIONS

This paper begins to point to effective interventions that will improve type II diabetes management for people with schizophrenia or other schizoaffective disorders.

Diabetic ketoacidosis associated with aripiprazole

BACKGROUND

Atypical antipsychotics have become the mainstay of management of schizophrenia and other psychotic disorders due to low risk of extrapyramidal symptoms. However, postmarketing data has reported atypical antipsychotic agents being associated with hyperglycaemia and diabetic ketoacidosis (DKA). We believe this to be the first published report of hyperglycaemia and DKA with the newest atypical antipsychotic agent, aripiprazole.

CASE REPORT

A 34-year-old African-American female with schizophrenia presented to the emergency department with nausea, vomiting, and malaise for 3-4 days shortly after initiation of aripiprazole therapy. Initial laboratory results revealed significant hyperglycaemia with metabolic acidosis. The patient received treatment for DKA with an intravenous insulin infusion and fluid replacement. Isophane insulin suspension (NPH insulin) was begun immediately following the insulin drip and continued upon discharge from the hospital. Outpatient follow-up information was not available.

CONCLUSION

To our knowledge, this is the first case report of aripiprazole associated with hyperglycaemia and DKA. This case is striking in that DKA occurred 4 days following initiation of aripiprazole and the patient had rapid resolution of symptoms and normalization of laboratory values upon discontinuation of aripiprazole. It is important that health-care providers monitor for hyperglycaemia when prescribing atypical antipsychotics including aripiprazole.