Antipsychotics can increase metabolic risk factors

Since their introduction in the 1990s, atypical antipsychotics have become the drugs of choice for the treatment of schizophrenia. However, these drugs are associated with a high incidence of weight gain or other metabolic side effects, influencing glucose and lipid metabolism.

Additionally, patients with chronic mental illnesses have been found to be associated with a higher mortality rate than people in the general population. "Our patients are the sickest and the least likely to receive care. We have a serious problem with respect to morbidity and mortality. There are evidence-based data that this problem is there and the public sector needs to act," added Henry Nasrallah, M.D., professor of psychiatry and neuroscience, University of Cincinnati College of Medicine.

CATIE shed some insights about the fact that antipsychotic selection is not a straightforward process. All study medications showed significant improvements on the Positive & Negative Syndrome Scale (PANSS). "Olanzapine had favorable efficacy but worse metabolic side effects compared with other drugs in CATIE," stated Ryan Carnahan, Pharm.D., assistant professor in the department of pharmacy, clinical and administrative sciences, University of Oklahoma College of Pharmacy.

"In the olanzapine-treated patients, there was a statistically and clinically significant difference in weight gain, cholesterol, and triglycerides," added Daniel Haupt, M.D., assistant professor at Washington University in St. Louis School of Medicine.

Pharmacists can have an impact by trying to ensure that patients are getting proper screening for these disorders. "We can make recommendations for monitoring and screening," said Carnahan. "Of course, counseling is important as well. We should definitely inform patients that the medications may affect their appetite, discuss monitoring for weight gain and related metabolic problems, and possibly recommend dietary counseling for some patients."

Nasrallah believes psychiatrists also need to be involved in counseling patients about their health status. "We need to inform patients about having a balanced low-fat diet, exercising regularly, and stopping smoking if they do smoke," he said. "The most important thing is to make sure the patients have a primary healthcare provider.... [who] can monitor patients for these risk factors."

Patient-specific factors must be considered, and response to treatment should be periodically assessed so the most effective long-term treatment is determined. "When designing a treatment plan, we must consider our patients' physical health," said Nasrallah. "We must start patients on the metabolically safest atypical first and optimize the dose. If the patient does not respond to the first agent, then we try another one."

With regard to choosing appropriate therapy, pharmacists can help physicians weigh the risk/benefit of using different antipsychotics and try to ensure that patients get appropriate treatment for metabolic disorders if they occur, Carnahan said. "We might change our initial treatment choice based on side effects, but ultimately we want a drug that works for the psychiatric symptoms, and sometimes this is a drug with an unfavorable metabolic side-effect profile. We always keep physical problems in mind when selecting antipsychotics," he concluded.