Antipsychotic-Induced Metabolic Syndrome: A Review

Schizophrenia, a serious psychiatric disorder, is among the top 10 global causes of disability and affects nearly 1% of the world population. Antipsychotics constitute the best treatment for patients with schizophrenia, however, this treatment class carries a high risk of metabolic syndrome, including lipid abnormalities. Indeed, the risk of metabolic syndrome would be increased in the population with schizophrenia compared to the general population. The objective is to summarize the prevalence, the mechanisms, and the potential treatments of antipsychotic-induced metabolic syndrome. This is a narrative review of the literature. We searched the electronic database Medline, accessed through PubMed, to find studies that investigated the prevalence and treatments of metabolic syndrome in the adult population using antipsychotics. The prevalence of metabolic syndrome in patients treated with antipsychotics ranges from 37% to 63%. Antipsychotic iatrogenic effects include weight gain/increased waist circumference, dyslipidemia, insulin resistance/type 2 diabetes, and hypertension. Clozapine and olanzapine are reported to precipitate the onset of metabolic syndrome features. In patients with metabolic syndrome, an antipsychotic with less metabolic side effects such as lurasidone, lumateperone, ziprasidone, and aripiprazole should be prioritized. Unlike medications, aerobic exercise and dietetic counseling were found to be efficient as the nonpharmacologic treatment of antipsychotic-induced metabolic syndrome. Few pharmacological treatments were proven effective against weight gain in this patient population. The risk of metabolic syndrome induced by antipsychotics should be early recognized and closely monitored. Primary and secondary prevention of metabolic syndrome or onset of its feature might help reduce the risk of death for patients using antipsychotics.

Psychiatric and non-psychiatric polypharmacy among older adults with schizophrenia: Trends from a population-based study between 2000 and 2016

Background: Schizophrenia is a severe psychiatric disorder associated with multiple psychiatric and non-psychiatric comorbidities. As adults with schizophrenia age, they may use many medications, i.e., have polypharmacy. While psychiatric polypharmacy is well documented, little is known about trends and patterns of global polypharmacy. This study aimed to draw a portrait of polypharmacy among older adults with schizophrenia from 2000 to 2016. Methods: This population-based cohort study was conducted using the data of the Quebec Integrated Chronic Disease Surveillance System of the National Institute of Public Health of Quebec to characterize recent trends and patterns of medication use according to age and sex. We identified all Quebec residents over 65 years with an ICD-9 or ICD-10 diagnosis of schizophrenia between 2000 and 2016. We calculated the total number of medications used by every individual each year and the age-standardized proportion of individuals with polypharmacy, as defined by the usage of 5+, 10+, 15+, and 20+ different medications yearly. We identified the clinical and socio-demographic factors associated with polypharmacy using robust Poisson regression models considering the correlation of the responses between subjects and analyzed trends in the prevalence of different degrees of polypharmacy. Results: From 2000 to 2016, the median number of medications consumed yearly rose from 8 in 2000 to 11 in 2016. The age-standardized proportion of people exposed to different degrees of polypharmacy also increased from 2000 to 2016: 5+ drugs: 76.6%-89.3%; 10+ drugs: 36.9%-62.2%; 15+: 13.3%-34.4%; 20+: 3.9%-14.4%. Non-antipsychotic drugs essentially drove the rise in polypharmacy since the number of antipsychotics remained stable (mean number of antipsychotics consumed: 1.51 in 2000 vs. 1.67 in 2016). In the multivariate regression, one of the main clinically significant factor associated with polypharmacy was the number of comorbidities (e.g., Polypharmacy-10+: RR_{[2 VS. 0-1]} = 1.4; 99% IC:1.3-1.4, RR_[3-4] = 1.7 (1.7-1.8); RR_[5+] = 2.1 (2.1-2.2); Polypharmacy-15+: RR_{[2 VS 0-1]} = 1.6; 99% IC:1.5-1.7, RR_[3-4] = 2.5 (2.3-2.7); RR_[5+] = 4.1 (3.8-4.5). Conclusion: There was a noticeable increase in polypharmacy exposure among older adults with schizophrenia in recent years, mainly driven by non-antipsychotic medications. This raises concerns about the growing risks for adverse effects and drug-drug interactions in this vulnerable population.

A Longitudinal Study on the Impact of Indoor Temperature on Heat-Related Symptoms in Older Adults Living in Non-Air-Conditioned Households

BACKGROUND

Both chronic and acute heat result in a substantial health burden globally, causing particular concern for at-risk populations, such as older adults. Outdoor temperatures are often assessed as the exposure and are used for heat warning systems despite individuals spending most of their time indoors. Many studies use ecological designs, with death or hospitalizations rates. Individual-level outcomes that are directly related to heat-symptoms should also be considered to refine prevention efforts.

OBJECTIVES

In this longitudinal study, we assessed the association between indoor temperature and proximal symptoms in individuals ≥60 years of age living in non-air-conditioned households in Montérégie, Quebec, during the 2017-2018 summer months.

METHODS

We gathered continuously measured indoor temperature and humidity from HOBO sensors and repeated health-related questionnaires about health-related symptoms administered across three periods of increasing outdoor temperatures, where the reference measurement (T1) occurred during a cool period with a target temperature of 18-22°C and two measurements (T2 and T3) occurred during warmer periods with target temperatures of 28-30°C and 30-33°C, respectively. We used generalized estimating equations with Poisson regression models and estimated risk ratios (RRs) between temperature, humidity, and each heat-related symptom.

RESULTS

Participants (n=277) had an average age (mean±standard deviation) of 72.8±7.02y. Higher indoor temperatures were associated with increased risk of dry mouth (T3 RR=2.5; 95% CI: 1.8, 3.5), fatigue (RR=2.3; 95% CI: 1.8, 3.0), thirst (RR=3.4; 95% CI: 2.5, 4.5), less frequent urination (RR=3.7; 95% CI: 1.8, 7.3), and trouble sleeping (RR=2.2; 95% CI: 1.6, 3.2) compared with T1. We identified a nonlinear relationship with indoor temperatures across most symptoms of interest.

DISCUSSION

This study identified that increasing indoor temperatures were associated with various health symptoms. By considering the prevalence of these early stage outcomes and indoor temperature exposures, adaptation strategies may be improved to minimize the burden of heat among vulnerable communities. https://doi.org/10.1289/EHP10291.

Depression and the risk of hospitalization in type 2 diabetes patients: A nested case-control study accounting for non-persistence to antidiabetic treatment

INTRODUCTION

Depression is one of the most common comorbidities of type 2 diabetes. The relationship between these two diseases seems to be bidirectional. Both conditions separately lead to significant morbidity and mortality, including hospitalization. Moreover, depression is associated with non-persistence with antidiabetic drugs.

OBJECTIVES

To measure the effect of depression on morbidity and particularly on all-cause, diabetes-related, cardiovascular-related and major cardiovascular events-related hospitalization, adjusting for non-persistence to antidiabetic drugs and other confounders.

METHODS

We performed a nested case-control study within a cohort of type 2 diabetic individuals initiating antidiabetic drugs. Using the health administrative data of the province of Quebec, Canada, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular hospitalizations during a maximum follow-up of eight years after the initiation of antidiabetic drug treatment. A density sampling method matched all cases with up to 10 controls by age, sex, and the Elixhauser comorbidity index. The effect of depression on hospitalization was estimated using conditional logistic regressions adjusting for non-persistence to antidiabetic drug treatment and other variables.

RESULTS

We identified 41,550 all-cause hospitalized cases, of which 34,437 were related to cardiovascular (CV) diseases, 29,584 to diabetes, and 13,867 to major CV events. Depression was diagnosed in 2.51% of all-cause hospitalizations and 1.16% of matched controls. 69.11% of cases and 72.59% of controls were on metformin monotherapy. The majority (71.62% vs 75.02%, respectively) stayed on metformin monotherapy without adding or switching drugs during follow-up. Non-persistence was at similar rates (about 30%) in both groups. In the multivariable analyses, depression was associated with an increased risk for all-cause hospitalizations, with odds ratios (ORs) ranging from 2.21 (95% CI: 2.07-2.37) to 1.32 (95% CI: 1.22-1.44) according to the model adjustment (from the univariate to the fully adhjusted).

CONCLUSION

Depression increased the risk of all-cause hospitalizations among patients treated for diabetes, even after accounting for non-persistence and other potentially confounding factors. These results stress the impact of depression on diabetic patients' use of health care resources.

Effects of bariatric surgery on lipid-lipoprotein profile

Most patients with severe obesity will present some lipid-lipoprotein abnormalities. The atherogenic dyslipidemia associated with severe obesity is characterized by elevated fasting and postprandial triglyceride levels, low high-density lipoprotein cholesterol concentrations, and increased proportion of small and dense low-density lipoproteins. Bariatric surgery has been proven safe and successful in terms of long-term weight loss and improvement in obesity co-existing metabolic conditions including lipid-lipoprotein abnormalities. Nevertheless, bariatric surgery procedures are not all equivalent. We conducted a comprehensive critical analysis of the literature related to severe obesity, bariatric surgery and lipid-lipoprotein metabolism/profile. In this review, we described the metabolic impacts of different bariatric surgery procedures on the lipid-lipoprotein profile, and the mechanisms linking bariatric surgery and dyslipidemia remission based on recent epidemiological, clinical and preclinical studies. Further mechanistic studies are essential to assess the potential of bariatric/metabolic surgery in the management of lipid-lipoprotein abnormalities associated with severe obesity. Understanding the beneficial effects of various bariatric surgery procedures on the lipid-lipoprotein metabolism and profile may result in a wider acceptance of this strategy as a long-term metabolic treatment of lipid-lipoprotein abnormalities in severe obesity and help clinician to develop an individualized and optimal approach in the management of dyslipidemia associated with severe obesity. BRIEF SUMMARY: Abnormal lipid-lipoprotein profile is frequent in patients with severe obesity. Significant improvements in lipid-lipoprotein profile following bariatric surgery occur early in the postoperative period, prior to weight loss, and persists throughout the follow-up. The mechanisms that facilitate the remission of dyslipidemia after bariatric surgery, may involve positive effects on adipose tissue distribution/function, insulin sensitivity, liver fat content/function and lipid-lipoprotein metabolism.

Depression but not non-persistence to antidiabetic drugs is associated with mortality in type 2 diabetes: A nested case-control study

AIMS

To measure the effect of depression on mortality of individuals newly treated with antidiabetic drugs, accounting for non-persistence to treatment.

METHODS

We conducted a nested case-control study within a cohort of newly treated individuals with diabetes. Using Quebec administrative data, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular event deaths during a maximum follow-up of eight years. Each case was matched with up to 10 controls by age, sex, follow-up, and comorbidity index. We used conditional logistic regressions to estimate the effect of depression on mortality, adjusting for non-persistence to antidiabetic drug treatment, and other variables.

RESULTS

We retrieved 13,558 deaths, of which 3,652 were related to cardiovascular diseases, 2,112 to major cardiovascular events, and 311 to diabetes. Depression was associated with an increased risk of all-cause and cardiovascular-related deaths, with adjusted odds ratios (ORs) ranging from 1.32 (95% CI: 1.21-1.45) to 1.72 (95% CI: 1.57-1.88) depending on the model, but not with diabetes-related mortality.

CONCLUSION

Depression is independently associated with all-cause and cardiovascular-related mortality in individuals with type 2 diabetes, even when adjusting for non-persistence to antidiabetic drug treatment. Identifying risk factors for depression and implementing a screening and proper treatment for depression may help reducing mortality.