APA: Metabolic Risks Ignored in Choice of Atypical Antipsychotics

SAN DIEGO, May 24 -- Despite potential health consequences, the metabolic status of patients appears to have little bearing on clinicians' choices of an atypical antipsychotic agent, said investigators here.

In a retrospective study of nearly 1,000 patients who had a metabolic screening in the six months before receiving an atypical antipsychotic agent, neither cholesterol levels, triglycerides or fasting blood glucose results were associated with the choice of drug, reported Elaine H. Morrato, Dr.P.H., of the University of Colorado in Denver, and colleagues.

Atypical antipsychotic agents have been associated with metabolic changes such as weight gain, dyslipidemia, and hyperglycemia. Both the American Psychiatric Association and American Diabetes Association recommend routine metabolic screening and consideration of a patient's metabolic status when selecting an atypical antipsychotic, the authors noted in a poster presentation at American Psychiatric Association meeting.

Yet physicians report that fewer than 25% of patients are screened for lipids or glucose status prior to being started on a drug, and even when patients are screened for metabolic risk factors, their physicians don't always take the information into consideration when planning treatment with an antipsychotic agent, the investigators wrote.

The findings are emblematic of the failure of modern medicine to fully integrate the treatment of the mind with the treatment of the body, commented Thomas Wise, M.D., chairman of psychiatry at Inova Fairfax Hospital in Fairfax, Va., who was not involved in the study.

"In order to have the proper treatment, one cannot partition mind from body," he said. "In addition to a system that doesn't work, we have completely partitioned psychiatric care from medical care. It may be an overstatement or hyperbole, but somebody's going to have to prove to me that it's not true."

Dr. Morrato and colleagues conducted a retrospective review of lab assessments performed from 1999 to 2004 on 989 adult patients in the six months before they were started on an atypical antipsychotic agent, either olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon) or aripiprazole (Abilify).

They also looked at data on 196 patients three months after they were started on therapy with one of the agents. The information on the patients came from the database of a commercial health plan.

The authors conducted separate analyses to determine whether there were correlations between drug choice and specific metabolic components, including total cholesterol, triglycerides, and fasting blood glucose.

They defined increased baseline metabolic risk according to the National Cholesterol Education Program III and American Diabetes Association guidelines. These criteria include:

• Total cholesterol of 200 mg/dL or greater
• Triglycerides of 200 mg/dL or greater
• Fasting blood glucose of 126 mg/dL or greater.

They found that the choice of an initial atypical antipsychotic was significantly associated with baseline psychiatric disorders such as post-traumatic stress, bipolar disorder, schizophrenia, depression and psychosis (P