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C.21.01 Metabolic health issues in patients with schizophrenia
S612
C.21. Tolerability of atypical antipsychotics: recent controversies and future management
References [1] Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, den Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen HU, British Association for Psychopharmacology, 2005, Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 19, 567–596. [2] Kennedy SH, Andersen HF, Lam RW, 2006, Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a metaanalysis. Rev Psychiatr Neurosci 31, 122–131.
C.21. Tolerability of atypical antipsychotics: recent controversies and future management C.21.01 Metabolic health issues in patients with schizophrenia C.U. Correll ° . The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, USA Death due to cardiovascular (CV) complications represents the leading natural cause of excess mortality in patients with schizophrenia. Lifestyle factors including smoking, poor diet, and lack of exercise all contribute to CV disease. Additionally, research has focused on the “metabolic syndrome” – a cluster of abnormalities that identifies a group of individuals at increased risk for both CV disease and type 2 diabetes. Obesity – the core abnormality of metabolic syndrome – is more common among patients with schizophrenia than the general population. Obesity, especially abdominal obesity, in psychiatric patients should be considered an indicator of metabolic health problems. To improve long-term health outcomes, there is an urgent need to identify schizophrenia patients at risk of obesity earlier and effectively manage those who present with weight gain. One simple strategy includes the careful choice of antipsychotics that differ in their propensity to induce weight gain and metabolic abnormalities. Moreover, patients should undergo routine metabolic monitoring of weight, waist circumference, blood pressure, and fasting blood glucose and lipid levels. Early weight gain has been shown to be a good indicator of continued weight gain. In addition, monitoring of waist circumference is a simple, sensitive measure, and combined with fasting blood glucose levels, provides a convenient, cost-effective screening for metabolic risk. Patients should be counselled about healthy lifestyle behaviours and when relevant abnormalities are detected, these should be managed appropriately. When weight gain does occur, consensus guidelines recommend medication switching to an agent with lower metabolic risk profile [1]. References [1] ADA, 2004, Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27, 596–601.
C.21.02 Long-term treatment with atypical antipsychotics: establishing a balance between efficacy and tolerability A.H.
Heald ° .
Imperial College, London, United Kingdom
Clinical effectiveness of antipsychotic treatments is an area that has received increasing attention in recent years. Randomised,
placebo-controlled trials have provided valuable information on the long-term efficacy and tolerability of antipsychotic agents, but cannot address all of the variables that may influence treatment outcome in real-life clinical practice. Side effects associated with some antipsychotics, such as motor symptoms, symptoms of metabolic syndrome, and excessive sedation have a negative impact on patients’ daily functioning, long-term health and overall quality of life. In turn, these negative outcomes impact adversely on efficacy. Other factors such as subjective well-being, cognitive function and patients’ attitudes towards medication can also influence efficacy. These wider treatment issues are better evaluated in more naturalistic study design. In addition, patient populations enrolled in clinical trials are often not reflective of the wider population with schizophrenia, for example in terms of concomitant medication use or substance abuse. Thus, naturalistic studies that enrol a wide range of patients and reflect the conditions of clinical practice are an important means of providing additional data on the safety and efficacy of antipsychotic agents in ‘real-world’ settings and can help to inform clinical decision making. Given the similar efficacy of antipsychotics the metabolic risk profile should be considered when initiating or changing therapy. Appropriate monitoring and management strategies are vital to ensure a healthy outcome in patients receiving antipsychotic medication. C.21.03 Management strategies for patients with a present or emerging health risk M. De Hert ° . UPC KU, Leuven Campus, Kortenberg, Belgium Patients with psychiatric disorders do not receive adequate recognition of, monitoring of, or care for their medical illnesses. Due to the serious health consequences of metabolic syndrome, hyperglycaemia and dyslipidaemia, clinical attention must be given to managing the metabolic effects of some antipsychotics. This presentation will review the current guidelines for monitoring and management of metabolic health issues and provide directions for future improvements. Baseline and continued, interim assessment of metabolic risk is consistently recommended by all guidelines and is important for patients switching, as well as those initiating, antipsychotic therapy. However, there is a need for greater consistency regarding which parameters to monitor and at what time points. For example, the ADA recommend monitoring patient’s weight (4, 8, 12 weeks and quarterly) after starting or switching therapy and assessment of fasting plasma glucose, lipid levels and blood pressure 3 months after initiation. Other guidelines give limited recommendations for ongoing monitoring, focusing on glucose regulation. Also, better guidance on the selection of an antipsychotic for patients at risk of metabolic complications is also required. Recommendations for patients who gained weight or who have abnormal lipid profiles generally include a combination of diet and lifestyle changes, and medication switching. All guidelines suggest that patients showing weight gain may benefit from an antipsychotic switch [1], with the ADA suggesting a threshold gain of >5% to warrant switching. Now is the time to implement effectively the existing guidelines and address metabolic complications in psychiatry. References [1] Cohn Sernyak, 2006, Can J Psychiatry 51, 492–501.
C.21. Tolerability of atypical antipsychotics: recent controversies and future management
References [1] Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, den Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen HU, British Association for Psychopharmacology, 2005, Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 19, 567–596. [2] Kennedy SH, Andersen HF, Lam RW, 2006, Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a metaanalysis. Rev Psychiatr Neurosci 31, 122–131.
C.21. Tolerability of atypical antipsychotics: recent controversies and future management C.21.01 Metabolic health issues in patients with schizophrenia C.U. Correll ° . The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, USA Death due to cardiovascular (CV) complications represents the leading natural cause of excess mortality in patients with schizophrenia. Lifestyle factors including smoking, poor diet, and lack of exercise all contribute to CV disease. Additionally, research has focused on the “metabolic syndrome” – a cluster of abnormalities that identifies a group of individuals at increased risk for both CV disease and type 2 diabetes. Obesity – the core abnormality of metabolic syndrome – is more common among patients with schizophrenia than the general population. Obesity, especially abdominal obesity, in psychiatric patients should be considered an indicator of metabolic health problems. To improve long-term health outcomes, there is an urgent need to identify schizophrenia patients at risk of obesity earlier and effectively manage those who present with weight gain. One simple strategy includes the careful choice of antipsychotics that differ in their propensity to induce weight gain and metabolic abnormalities. Moreover, patients should undergo routine metabolic monitoring of weight, waist circumference, blood pressure, and fasting blood glucose and lipid levels. Early weight gain has been shown to be a good indicator of continued weight gain. In addition, monitoring of waist circumference is a simple, sensitive measure, and combined with fasting blood glucose levels, provides a convenient, cost-effective screening for metabolic risk. Patients should be counselled about healthy lifestyle behaviours and when relevant abnormalities are detected, these should be managed appropriately. When weight gain does occur, consensus guidelines recommend medication switching to an agent with lower metabolic risk profile [1]. References [1] ADA, 2004, Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27, 596–601.
C.21.02 Long-term treatment with atypical antipsychotics: establishing a balance between efficacy and tolerability A.H.
Heald ° .
Imperial College, London, United Kingdom
Clinical effectiveness of antipsychotic treatments is an area that has received increasing attention in recent years. Randomised,
placebo-controlled trials have provided valuable information on the long-term efficacy and tolerability of antipsychotic agents, but cannot address all of the variables that may influence treatment outcome in real-life clinical practice. Side effects associated with some antipsychotics, such as motor symptoms, symptoms of metabolic syndrome, and excessive sedation have a negative impact on patients’ daily functioning, long-term health and overall quality of life. In turn, these negative outcomes impact adversely on efficacy. Other factors such as subjective well-being, cognitive function and patients’ attitudes towards medication can also influence efficacy. These wider treatment issues are better evaluated in more naturalistic study design. In addition, patient populations enrolled in clinical trials are often not reflective of the wider population with schizophrenia, for example in terms of concomitant medication use or substance abuse. Thus, naturalistic studies that enrol a wide range of patients and reflect the conditions of clinical practice are an important means of providing additional data on the safety and efficacy of antipsychotic agents in ‘real-world’ settings and can help to inform clinical decision making. Given the similar efficacy of antipsychotics the metabolic risk profile should be considered when initiating or changing therapy. Appropriate monitoring and management strategies are vital to ensure a healthy outcome in patients receiving antipsychotic medication. C.21.03 Management strategies for patients with a present or emerging health risk M. De Hert ° . UPC KU, Leuven Campus, Kortenberg, Belgium Patients with psychiatric disorders do not receive adequate recognition of, monitoring of, or care for their medical illnesses. Due to the serious health consequences of metabolic syndrome, hyperglycaemia and dyslipidaemia, clinical attention must be given to managing the metabolic effects of some antipsychotics. This presentation will review the current guidelines for monitoring and management of metabolic health issues and provide directions for future improvements. Baseline and continued, interim assessment of metabolic risk is consistently recommended by all guidelines and is important for patients switching, as well as those initiating, antipsychotic therapy. However, there is a need for greater consistency regarding which parameters to monitor and at what time points. For example, the ADA recommend monitoring patient’s weight (4, 8, 12 weeks and quarterly) after starting or switching therapy and assessment of fasting plasma glucose, lipid levels and blood pressure 3 months after initiation. Other guidelines give limited recommendations for ongoing monitoring, focusing on glucose regulation. Also, better guidance on the selection of an antipsychotic for patients at risk of metabolic complications is also required. Recommendations for patients who gained weight or who have abnormal lipid profiles generally include a combination of diet and lifestyle changes, and medication switching. All guidelines suggest that patients showing weight gain may benefit from an antipsychotic switch [1], with the ADA suggesting a threshold gain of >5% to warrant switching. Now is the time to implement effectively the existing guidelines and address metabolic complications in psychiatry. References [1] Cohn Sernyak, 2006, Can J Psychiatry 51, 492–501.