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Alastanos JN, Suri D, DeLellis H, Mapugay A. A case report and literature review of olanzapine-associated hyperglycemia with previous history of gestational diabetes. Ment Health Clin 2022; 12:37-44. [PMID: 35116211 PMCID: PMC8788302 DOI: 10.9740/mhc.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
| | - Devika Suri
- Clinical Pharmacist, St Joseph's Hospital, Tampa, Florida
| | - Hayato DeLellis
- Internal Medicine Clinical Pharmacist, St Joseph's Hospital, Tampa, Florida
| | - Andrea Mapugay
- PGY-1 Pharmacy Resident, St Joseph's Hospital, Tampa, Florida
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2
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Folnegović-Smalc V, Jukić V, Kozumplik O, Mimica N, Uzun S. Olanzapine use in a patient with schizophrenia and the risk of diabetes. Eur Psychiatry 2020; 19:62-4. [PMID: 14969784 DOI: 10.1016/j.eurpsy.2003.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2002] [Revised: 08/29/2003] [Accepted: 09/11/2003] [Indexed: 11/21/2022] Open
Affiliation(s)
- V Folnegović-Smalc
- University Department of Psychiatry, Psychiatric Hospital Vrapce, Bolnicka cesta 32, 10090 Zagreb, Croatia
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Abosi O, Lopes S, Schmitz S, Fiedorowicz JG. Cardiometabolic effects of psychotropic medications. Horm Mol Biol Clin Investig 2018; 36:hmbci-2017-0065. [PMID: 29320364 DOI: 10.1515/hmbci-2017-0065] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/18/2017] [Indexed: 12/27/2022]
Abstract
Background Many psychiatric disorders including schizophrenia, bipolar disorder and major depression convey an excess burden of cardiovascular morbidity and mortality. The medications used to treat these conditions may further adversely affect cardiovascular risk and exacerbate health disparities for vulnerable populations. There is a clinical need to appreciate the cardiometabolic adverse effects of psychotropic medications. Methods This paper reviews the most relevant cardiometabolic effects of psychotropic medications, organized around the components of metabolic syndrome. When known, the molecular and physiological mechanisms underlying any adverse cardiometabolic effects are detailed. Results Many commonly used psychotropic medications, particularly antipsychotics, mood stabilizers and some antidepressants, have been independently associated with cardiometabolic risk factors such as insulin resistance, obesity and dyslipidemia. Stimulants, antidepressants that inhibit reuptake of norepinephrine, some antipsychotics and valproic acid derivatives may also increase blood pressure. Conclusion Understanding, assessing and subsequently managing cardiometabolic complications of psychotropic medications are important to mitigate the excess cardiovascular morbidity and mortality in the clinical populations prescribed psychotropic medications. There is considerable variability in risk between medications and individuals. Timely management of iatrogenic cardiometabolic effects is critical.
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Affiliation(s)
- Oluchi Abosi
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Sneha Lopes
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Samantha Schmitz
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA.,Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Jess G Fiedorowicz
- Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA.,Department of Psychiatry, The University of Iowa, 200 Hawkins Drive, W278 GH, Iowa City, IA 52242, USA, Phone: +319-384-9267.,Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA.,François M. Abboud Cardiovascular Research Center, The University of Iowa, Iowa City, IA, USA.,Iowa Neuroscience Institute, The University of Iowa, Iowa City, IA, USA.,Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA, USA
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Vuk A, Baretic M, Osvatic MM, Filipcic I, Jovanovic N, Kuzman MR. Treatment of Diabetic Ketoacidosis Associated With Antipsychotic Medication: Literature Review. J Clin Psychopharmacol 2017; 37:584-589. [PMID: 28816925 PMCID: PMC5596830 DOI: 10.1097/jcp.0000000000000772] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 07/03/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Antonia Vuk
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Maja Baretic
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martina Matovinovic Osvatic
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Igor Filipcic
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Jovanovic
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martina Rojnic Kuzman
- From the *Psychiatric Hospital Sveti Ivan; †Zagreb School of Medicine; ‡Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia; §Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London, United Kingdom; and ∥Department of Psychiatry, University Hospital Centre Zagreb, Zagreb, Croatia
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5
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Buch H, Clifford G, Barton D, Scarpello J. Diabetic ketoacidosis secondary to olanzapine. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/14746514030030051201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - John Scarpello
- Department of Diabetes and Endocrinology, Nines block, North Staffordshire Hospital, Stoke-on-Trent, ST4 6QG, UK,
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6
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Suehs BT, Bettinger TL, Hall CS. Atypical Antipsychotics and Diabetes: Discussion and Monitoring Recommendations. J Pharm Technol 2016. [DOI: 10.1177/875512250502100103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective:To discuss the relationship between atypical antipsychotics (AAPs) and diabetes and to report new monitoring recommendations for patients being prescribed AAPs.Data Sources:Articles were identified through searches of MEDLINE and PubMed (1966–March 2004). Search terms included hyperglycemia, diabetes, glucose, atypical antipsychotics, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Only articles published in the English language were included in the search. Additionally, bibliographies of articles cited were used to identify additional articles.Study Selection and Data Extraction:All available articles identified by the data sources were reviewed and those deemed relevant to the review were included.Data Synthesis:Information pertaining to diabetes/hyperglycemia risk in case reports and submissions to the Medwatch system prompted the FDA to require labeling changes for all AAPs. The exact relationship between AAPs and diabetes remains unclear. The association is clouded by the fact that patients with schizophrenia are, in general, at higher risk for diabetes mellitus. Sedentary lifestyle and poor dietary intake are 2 possible contributing causes of diabetes in patients with schizophrenia. Weight gain or other metabolic effects of AAPs may put patients at further risk of developing diabetes. The American Diabetes Association, American Psychiatric Association, American Association of Clinical Epidemiologists, and North American Association for the Study of Obesity have released a joint consensus statement addressing some of the concerns related to AAP use.Conclusions:Because of the apparent increased risk of diabetes in patients taking AAPs, monitoring weight, fasting blood glucose, blood pressure, and lipids should be a part of the baseline assessment and ongoing care.
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Affiliation(s)
- Brandon T Suehs
- BRANDON T SUEHS PharmD, Psychiatric Pharmacy Practice Resident, College of Pharmacy, The University of Texas at Austin, Austin, TX
| | - Tawny L Bettinger
- TAWNY L BETTINGER PharmD BCPP, Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, The University of Texas at Austin
| | - Catherine S Hall
- CATHERINE S HALL PharmD BCPP, Clinical Pharmacist, Bluebonnet Trails Community Mental Health Center, Seguin, TX
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7
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Guenette MD, Hahn M, Cohn TA, Teo C, Remington GJ. Atypical antipsychotics and diabetic ketoacidosis: a review. Psychopharmacology (Berl) 2013; 226:1-12. [PMID: 23344556 DOI: 10.1007/s00213-013-2982-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/19/2012] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Melanie D Guenette
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada M5S 1A8
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8
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Ely SF, Neitzel AR, Gill JR. Fatal diabetic ketoacidosis and antipsychotic medication. J Forensic Sci 2012; 58:398-403. [PMID: 23278567 DOI: 10.1111/1556-4029.12044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 02/14/2012] [Accepted: 02/19/2012] [Indexed: 11/30/2022]
Abstract
Hyperglycemia and new onset diabetes have been described with certain antipsychotic medications and some of the initial presentations are fatal diabetic ketoacidosis (DKA). We report 17 deaths due to DKA in psychiatric patients treated with second generation antipsychotic medications. Death certificates and toxicology data were searched for DKA and hyperglycemia. We reviewed the medical examiner records which included the autopsy, toxicology, police, and medical examiner investigators' reports. The decedents ranged in age from 32 to 57 years (average 48 years). There were 15 men and two women. The immediate cause of death was DKA in all. The psychiatric disorders included: 10 schizophrenia, three bipolar/schizophrenia, two bipolar, and two major depression. The most frequent atypical antipsychotic medications found were quetiapine and olanzapine followed by risperidone. In 16 deaths, we considered the medication as primary or contributory to the cause of death.
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Affiliation(s)
- Susan F Ely
- New York City Office of Chief Medical Examiner and Department of Forensic Medicine, New York University School of Medicine, 520 First Avenue, New York, NY, 10016
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9
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Smith GC, Vickers MH, Shepherd PR. Olanzapine effects on body composition, food preference, glucose metabolism and insulin sensitivity in the rat. Arch Physiol Biochem 2011; 117:241-9. [PMID: 21671852 DOI: 10.3109/13813455.2011.576681] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The atypical antipsychotic drug olanzapine induces weight gain and defects in glucose metabolism in patients. Using a rat model we investigated the effects of acute and long term olanzapine treatment on weight gain, food preference and glucose metabolism. Olanzapine treated rats fed a chow diet grew more slowly than vehicle controls but olanzapine treated animals fed a high fat/sugar diet grew faster than control animals on the same diet. These changes in weight were paralleled by changes in fat mass. Olanzapine also induced a strong preference for a high fat/high sugar diet. Acute exposure to olanzapine rapidly induced severe impairments of glucose tolerance and increased insulin secretion but did not impair insulin tolerance. These results indicate the defect in glucose metabolism induced by acute olanzapine treatment was most likely due to increased hepatic glucose output associated with a reduction in active GLP-1 levels and correspondingly high glucagon levels.
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Affiliation(s)
- G C Smith
- Department of Molecular Medicine and Pathology and Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
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10
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Smith GC, Vickers MH, Cognard E, Shepherd PR. Clozapine and quetiapine acutely reduce glucagon-like peptide-1 production and increase glucagon release in obese rats: implications for glucose metabolism and food choice behaviour. Schizophr Res 2009; 115:30-40. [PMID: 19679451 DOI: 10.1016/j.schres.2009.07.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 07/10/2009] [Accepted: 07/14/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Second generation antipsychotic drug (SGA) treatment is associated with detrimental effects on glucose metabolism which is often attributed to the development of obesity and insulin resistance. However, we have recently demonstrated that clozapine and quetiapine also have direct effects of glucose metabolism in animals. This study compares clozapine and quetiapine and investigates the effects of these on the development of obesity and the direct effects of these drugs on glucose metabolism compared with those caused by the obesity per se. RESEARCH DESIGN AND METHODS Three groups of male Sprague-Dawley rats were fed a high fat/high sugar diet to induce obesity while another three groups were fed a chow diet. One group on each diet was injected daily with vehicle, clozapine or quetiapine and effects on glucose metabolism were monitored. RESULTS Clozapine and quetiapine treatment did not directly cause obesity or potentiate diet induced obesity but did induce a preference for the high fat/high sugar diet. Neither drug caused a impairment in insulin tolerance over that caused by obesity but both drugs acutely induced impairments in glucose tolerance that were additive with the effects induced by the diet induced obesity. Both drugs caused increases in glucagon levels and a suppression of GLP-1. We investigated two strategies for restoring GLP-1 signalling. The DPP-IV inhibitor sitagliptin only partially restored GLP-1 levels and did not overcome the deleterious effects on glucose tolerance whereas the GLP-1 receptor agonist exendin-4 normalised both glucagon levels and glucose metabolism. CONCLUSIONS Our findings indicate that the clozapine and quetiapine induced impairments in glucose tolerance in rats are independent of insulin resistance caused by obesity and that these defects are linked with a suppression of GLP-1 levels. These studies suggest the need to perform follow up studies in humans to determine whether clozapine and quetiapine induce acute derangements in glucose metabolism and whether GLP-1 replacement therapy might be the most appropriate therapeutic strategy for treating derangements in glucose metabolism in subjects taking these drugs.
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Affiliation(s)
- Greg C Smith
- Department of Molecular Medicine and Pathology and Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
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11
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Herken H, Erdal M, Aydin N, Sengul C, Karadag F, Barlas O, Akin F. The association of olanzapine-induced weight gain with peroxisome proliferator-activated receptor-gamma2 Pro12Ala polymorphism in patients with schizophrenia. DNA Cell Biol 2009; 28:515-9. [PMID: 19622037 DOI: 10.1089/dna.2009.0893] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Olanzapine is a second-generation antipsychotic that may cause weight gain and metabolic syndrome in some cases. The peroxisome proliferator-activated receptor (PPAR)-gamma is an important gene in the progress of type II diabetes and metabolic syndrome. In recent studies the polymorphism of the PPAR-gamma has been studied in type II diabetes mellitus, polycystic ovary syndrome, and insulin resistance syndrome. It is aimed to evaluate the association between polymorphism of PPAR-gamma gene and olanzapine-induced weight gain. Our study comprised 95 unrelated subjects who strictly met Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for schizophrenia, and all were of Turkish origin. All patients were evaluated with rating scales, and genetic analyses were performed. We found statistically significant differences between pretreatment and posttreatment body mass index and weight change in Pro12Ala polymorphism of PPAR-gamma2. Our results suggest that genetic polymorphism of PPAR might be important in olanzapine-induced weight gain and that genetic variance of people might be considered in antipsychotic medication selection.
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Affiliation(s)
- Hasan Herken
- Department of Psychiatry, Pamukkale University , Denizli, Turkey
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12
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Abstract
Recently, increasing attention has been drawn to the potential diabetogenic effect of novel antipsychotics. Until now, large prospective studies examining the relationship between atypical antipsychotics and impaired glucose metabolism have been lacking. However, the case reports and retrospective studies that we review here suggest an increased risk of developing diabetes mellitus (DM) in patients treated with atypical antipsychotics compared to schizophrenic patients treated with conventional antipsychotics or those without treatment. Although most atypical antipsychotic agents might have a diabetogenic potential, the risk of developing DM might be higher in patients treated with either clozapine or olanzapine than with risperidone, whereas data on quetiapine and ziprasidone is presently limited and needs further attention. Possible mechanisms include the induction of peripheral insulin resistance and the direct influence on pancreatic beta-cell function by 5-HT1A/2A/2C receptor antagonism, by inhibitory effects via alpha 2-adrenergic receptors or by toxic effects. On the other hand, atypical antipsychotics might not be an independent risk factor for the development of DM, but hasten the onset of DM in patients bearing other risk factors. It is suggested that schizophrenic patients should be monitored for the occurrence of glucose metabolism abnormalities before starting atypical antipsychotics, and at a 3-month interval at least during therapy.
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Affiliation(s)
- Peter Schwenkreis
- Department of Psychiatry and Psychotherapty, Ruhr-University of Bochum, Germany
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13
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Insulin resistance and decreased glucose-stimulated insulin secretion after acute olanzapine administration. J Clin Psychopharmacol 2008; 28:494-9. [PMID: 18794643 DOI: 10.1097/jcp.0b013e318184b4c5] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The newer atypical antipsychotics, as a class, have been associated with an increased risk of weight gain and metabolic abnormalities. The mechanisms underlying this phenomenon are currently unclear, but there are data to suggest the possibility of an immediate (as opposed to chronic) effect of these drugs. The aim of the present study was to assess the acute effects of olanzapine on specific measures of insulin sensitivity and secretion. Healthy animals were tested in either the hyperinsulinemic-euglycemic or the hyperglycemic clamp. After reaching steady state in the hyperinsulinemic-euglycemic clamp, rats were injected with olanzapine (3 mg/kg sc) and monitored for an additional 130 minutes. In the hyperglycemic clamp, olanzapine was injected approximately 90 minutes before receiving a glucose bolus, and hyperglycemia was maintained via exogenous glucose infusion for an additional 90 minutes. Insulin and C-peptide levels were monitored throughout this clamp.Acute administration of olanzapine significantly lowered the glucose infusion rate due to an increase in hepatic glucose production and a decrease in glucose utilization. Olanzapine pretreatment induced hyperglycemia and markedly decreased plasma insulin and C-peptide in response to the glucose challenge. These findings indicate that olanzapine can directly induce metabolic changes that occur rapidly and well in advance of the changes that might be anticipated as a result of its weight-gain liability. We present novel findings highlighting an olanzapine-induced deficit in beta-cell functioning.
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Chintoh AF, Mann SW, Lam TKT, Giacca A, Remington G. Insulin resistance following continuous, chronic olanzapine treatment: an animal model. Schizophr Res 2008; 104:23-30. [PMID: 18675538 DOI: 10.1016/j.schres.2008.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Revised: 05/27/2008] [Accepted: 06/04/2008] [Indexed: 10/21/2022]
Abstract
Some atypical antipsychotics have been linked to an increased propensity for weight gain and metabolic disturbances, including type II diabetes. The objective of this study was to investigate an animal model to help understand the mechanisms underlying this phenomenon. Female, Sprague-Dawley rats were treated with olanzapine (2.0 or 7.5 mg/kg, via osmotic mini-pump) for 4 weeks, followed by the hyperinsulinemic/euglycemic and hyperglycemic clamp procedures to assess insulin sensitivity and secretion in vivo. Changes in body weight, visceral fat, food intake and locomotor activity were also assessed. Hepatic glucose production (R(A)) was increased in the hyperinsulinemic/euglycemic clamp for both treatment groups compared to control rats, while the high-dose olanzapine group had decreased peripheral glucose utilization (R(D)). No changes in insulin secretion were detected in the hyperglycemic clamp. Olanzapine did not change body weight or food intake, but did result in significant accumulation of visceral fat and decreases in locomotor activity. Like others, we found that a rodent model for antipsychotic-related weight gain per se is not tenable. However, chronic treatment with olanzapine was found to confer both hepatic and peripheral insulin resistance independent of weight gain, indicating a direct effect on glucose dysregulation.
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Affiliation(s)
- Araba F Chintoh
- Institute of Medical Science, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada M5S 1A8
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Reis JS, Alvarenga T, Rosário PWSD, Menezes PAFC, Rocha RDS, Purisch S. [Diabetes mellitus associated with atypical antipsychotic medications: case report and review of the literature]. ACTA ACUST UNITED AC 2008; 51:488-93. [PMID: 17546250 DOI: 10.1590/s0004-27302007000300019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 09/20/2006] [Indexed: 11/22/2022]
Abstract
Since the introduction of atypical antipsychotic medications, starting with clozapine in 1990, many studies have associated these drugs with the development of diabetes among other metabolic disorders, as well as with the onset of the disease as ketoacidosis. We report the case of a 28-year-old patient with schizophrenia who was admitted with diabetic acidosis 1 month after the beginning of clozapine therapy. No weight gain was reported and the patient maintains satisfactory glycemia levels with no treatment required after discontinuation of the drug. The literature on this subject and cases reported so far are reviewed, including the association of other atypical antipsychotic drugs also involved in endocrine disorders. The objective of this report is to raise the awareness of physicians treating psychiatric patients to the possibility of new-onset diabetes during therapy with atypical antipsychotic drugs and to emphasize the necessity for increased vigilance and close metabolic follow-up of these patients.
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Abstract
Coronary heart disease (CHD) is a major cause of mortality in people who have schizophrenia, and it is caused by many factors relating to lifestyle choices, antipsychotic treatment, and other medical comorbidities. This article focuses on modifiable risk factors such as cigarette smoking, diabetes, hyperlipidemia, hypertension, and the metabolic syndrome, all of which occur more frequently in patients who have schizophrenia than in the general population. Although treatment of risk factors for CHD is still far from ideal, all attempts should be made to strive for wellness to improve patients' long-term outcomes.
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Guo JJ, Keck PE, Corey-Lisle PK, Li H, Jiang D, Jang R, L'Italien GJ. Risk of diabetes mellitus associated with atypical antipsychotic use among Medicaid patients with bipolar disorder: a nested case-control study. Pharmacotherapy 2007; 27:27-35. [PMID: 17192159 DOI: 10.1592/phco.27.1.27] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To quantify the risk of diabetes mellitus associated with atypical antipsychotics compared with conventional antipsychotics in managed care Medicaid patients with bipolar disorder. DESIGN Retrospective nested case-control study. DATA SOURCE Integrated seven-state Medicaid managed care claims database from January 1, 1998-December 31, 2002. PATIENTS Two hundred eighty-three patients with diabetes (cases) and 1134 controls matched by age, sex, and the index date on which bipolar disorder was diagnosed. MEASUREMENTS AND MAIN RESULTS Cases were defined as those having an International Classification of Diseases, Ninth Revision diagnosis of diabetes or those receiving treatment with antidiabetic drugs. Both case and control patients had at least a 3-month exposure to either conventional or atypical antipsychotic agents or three filled prescriptions related to treatment for bipolar disorder. Of the 283 cases, 139 (49%) received atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone, and clozapine) and 133 (47%) were prescribed conventional antipsychotics. To compare the risk for new-onset diabetes associated with atypical versus conventional antipsychotics, we conducted a Cox proportional hazard regression, in which we controlled for age; sex; duration of bipolar disorder follow-up; use of lithium, anticonvulsants, antidepressants, and other drugs; and psychiatric and medical comorbidities. Compared with patients receiving conventional antipsychotics, the risk of diabetes was greatest among patients taking risperidone (hazard ratio [HR] 3.8, 95% confidence interval [CI] 2.7-5.3), olanzapine (3.7, 95% CI 2.5-5.3), and quetiapine (2.5, 95% CI 1.4-4.3). The risk for developing diabetes was also associated with weight gain (HR 2.5, 95% CI 1.9-3.4), hypertension (HR 1.6, 95% CI 1.2-2.2), and substance abuse (HR 1.5, 95% CI 1.0-2.2). CONCLUSION Olanzapine, risperidone, and quetiapine are all associated with development or exacerbation of diabetes mellitus in patients with bipolar disorder. When prescribing therapy for this patient population, metabolic complications such as diabetes, weight gain, and hypertension need to be considered.
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Affiliation(s)
- Jeff J Guo
- College of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio 45267-0004, USA.
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Lambert BL, Cunningham FE, Miller DR, Dalack GW, Hur K. Diabetes risk associated with use of olanzapine, quetiapine, and risperidone in veterans health administration patients with schizophrenia. Am J Epidemiol 2006; 164:672-81. [PMID: 16943266 DOI: 10.1093/aje/kwj289] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To evaluate risk of new-onset type 2 diabetes associated with use of selected antipsychotic agents, the authors conducted a new-user cohort study in a national sample of US Veterans Health Administration patients with schizophrenia (and no preexisting diabetes). The authors studied 15,767 patients who initiated use of olanzapine, risperidone, quetiapine, or haloperidol in 1999-2001 after at least 3 months with no antipsychotic prescriptions. Patients were followed for just over 1 year. New-onset diabetes was identified through diagnostic codes and prescriptions for diabetes medication. In Cox proportional hazards regression adjusting for potential confounders, with patients initiating haloperidol use designated the reference group, diabetes risk was increased equally with new use of olanzapine (hazard ratio (HR) = 1.64, 95% confidence interval (CI): 1.22, 2.19), risperidone (HR = 1.60, 95% CI: 1.19, 2.14), or quetiapine (HR = 1.67, 95% CI: 1.01, 2.76). Diabetes risks were higher in patients under age 50 years. When data were reanalyzed with prevalent-user cohorts and matched case-control designs, results were similar, with slightly less elevated risk estimates. Assuming that the observed associations are causal, approximately one third of new cases of diabetes may be attributed to use of olanzapine, risperidone, and quetiapine in patients taking these medications. Prescribers should be mindful of diabetes risks when treating patients with schizophrenia.
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Affiliation(s)
- Bruce L Lambert
- Department of Pharmacy Administration, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Østbye T, Curtis LH, Masselink LE, Hutchison S, Wright A, Dans PE, Schulman KA, Krishnan RR. Atypical antipsychotic drugs and diabetes mellitus in a large outpatient population: a retrospective cohort study. Pharmacoepidemiol Drug Saf 2006; 14:407-15. [PMID: 15372671 DOI: 10.1002/pds.1016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE Previous research has suggested an association between use of atypical antipsychotics and onset of diabetes mellitus. We sought to compare the incidence of new onset diabetes among patients receiving atypical antipsychotics, traditional antipsychotics or antidepressants. METHODS Retrospective cohort study of outpatients with claims for atypical antipsychotics (n = 10 265) compared to controls with claims for traditional antipsychotics (n = 4607), antidepressants (n = 60 856) or antibiotics (n = 59 878) in the administrative claims database of a large pharmaceutical benefit manager between June 2000 and May 2002. Main outcome measures were adjusted and unadjusted incidence rates of diabetes (new cases per 1000 per year) in a 12-month period, as measured using new prescriptions for antidiabetic drugs after a 6-month lead-in period. RESULTS Annual unadjusted incidence rates of diabetes (new cases per 1000 per year) were 7.5 for atypical antipsychotics, 11.3 for traditional antipsychotics, 7.8 for antidepressants and 5.1 for antibiotics. In multivariable analyses, age, male sex and Chronic Disease Score were associated with greater odds of diabetes onset. There were no statistically significant differences in outcome between the atypical antipsychotic, traditional antipsychotic and antidepressant groups. Multivariable comparisons among specific agents showed increased odds of diabetes for clozapine, olanzapine, ziprasidone and thioridazine (relative to risperidone), but these comparisons did not reach statistical significance. CONCLUSIONS In a large prescription claims database, outpatients taking atypical antipsychotics did not have higher rates of diabetes onset, compared to subjects taking traditional antipsychotics or antidepressants.
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Affiliation(s)
- Truls Østbye
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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20
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Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005; 150:1115-21. [PMID: 16338246 DOI: 10.1016/j.ahj.2005.02.007] [Citation(s) in RCA: 745] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2004] [Accepted: 02/07/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of the study is to review the absolute and relative impacts of the major causes for premature mortality among patients with schizophrenia. DATA SOURCES We reviewed published articles on causes of mortality in the general population as well as among patients with schizophrenia. STUDY SELECTION We selected articles which published total and cause-specific mortality rates. DATA EXTRACTION We reviewed the causes of mortality and their risk factors. DATA SYNTHESIS The average life expectancy of the general population is 76 years (72 years in men, 80 years in women), whereas the corresponding figure is 61 years (57 years in men, 65 years in women) among patients with schizophrenia. Thus, patients with schizophrenia have approximately a 20% reduced life expectancy compared with the general population. Although patients with schizophrenia are 10 to 20 times more likely than the general population to commit suicide, more than two thirds of patients with schizophrenia, compared with approximately one-half in the general population, die of coronary heart disease (CHD). The chief risk factors for this excess risk of death are cigarette smoking, obesity leading to dyslipidemia, insulin resistance and diabetes, and hypertension. CONCLUSIONS The chief cause of excess premature mortality among patients with schizophrenia is CHD, caused mainly by their adverse risk factor profile. Because patients with schizophrenia have less access to medical care, consume less medical care, and are less compliant with their regimens, the choice of antipsychotic drug regimens that do not further adversely affect their risk factor for CHD is a major clinical and public health challenge among patients with schizophrenia.
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Affiliation(s)
- Charles H Hennekens
- Department of Biomedical Science, Center of Excellence in Biomedical and Marine Biotechnology, Florida Atlantic University, FL, USA.
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21
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Kelly DL, Conley RR, Carpenter WT. First-episode schizophrenia: a focus on pharmacological treatment and safety considerations. Drugs 2005; 65:1113-38. [PMID: 15907146 DOI: 10.2165/00003495-200565080-00006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Schizophrenia is a debilitating disorder, which is usually chronic, and is one of the most devastating medical illnesses. Early and appropriate treatment with antipsychotics is an important strategy for patients with first-episode schizophrenia. However, there are many possible safety issues for patients with schizophrenia that should be considered and properly addressed. Depressive symptoms and suicidal behaviour commonly occur in first-episode schizophrenic patients, and every effort should be made to treat and minimise these symptoms. There are also important issues and considerations in young and first-episode patients that should also be considered in the emergency treatment setting and for minimising medication nonadherence in this population. Most importantly, adverse effects should be considered, minimised and addressed. While first- and second-generation antipsychotics (SGAs) both appear to offer similar efficacy for amelioration of positive symptoms in first-episode patients, SGAs may offer better tolerability, specifically regarding extrapyramidal symptoms (EPS) and tardive dyskinesia risk, and some prolactin-sparing benefits. However, these medications do cause a host of adverse effects, including weight gain, metabolic disturbances, corrected QT interval prolongation and prolactin-related adverse effects, which are important considerations relating to both the short- and long-term safety of patients with schizophrenia being treated with SGAs. Clozapine and olanzapine are most likely to cause weight gain and metabolic effects, while risperidone is more likely to cause EPS and prolactin elevations. Most antipsychotics should be used in low doses to minimise adverse effects and each medication should be optimised in a highly individualised way to maximise adherence and treatment outcomes and minimise tolerability and safety concerns. At some point in their lives, these patients will most probably experience periods of depression, suicidal behaviours, adverse effects and nonadherence, and every effort should be made to minimise or prevent these from occurring. Thus, safety concerns in this group of young patients, in the beginning of their first psychotic episode, are a major issue as they are starting a journey of antipsychotic treatment that is likely to last for the remainder of their lives.
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Affiliation(s)
- Deanna L Kelly
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21228, USA.
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22
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Abstract
Increasing numbers of reports concerning diabetes, ketoacidosis, hyperglycaemia and lipid dysregulation in patients treated with second-generation (or atypical) antipsychotics have raised concerns about a possible association between these metabolic effects and treatment with these medications. This comprehensive literature review considers the evidence for and against an association between glucose or lipid dysregulation and eight separate second-generation antipsychotics currently available in the US and/or Europe, specifically clozapine, olanzapine, risperidone, quetiapine, zotepine, amisulpride, ziprasidone and aripiprazole. This review also includes an assessment of the potential contributory role of treatment-induced weight gain in conferring risk for hyperglycaemia and dyslipidaemia during treatment with different antipsychotic medications. Substantial evidence from a variety of human populations, including some recent confirmatory evidence in treated psychiatric patients, indicates that increased adiposity is associated with a variety of adverse physiological effects, including decreases in insulin sensitivity and changes in plasma glucose and lipid levels. Comparison of mean weight changes and relative percentages of patients experiencing specific levels of weight increase from controlled, randomised clinical trials indicates that weight gain liability varies significantly across the different second generation antipsychotic agents. Clozapine and olanzapine treatment are associated with the greatest risk of clinically significant weight gain, with other agents producing relatively lower levels of risk. Risperidone, quetiapine, amisulpride and zotepine generally show low to moderate levels of mean weight gain and a modest risk of clinically significant increases in weight. Ziprasidone and aripiprazole treatment are generally associated with minimal mean weight gain and the lowest risk of more significant increases. Published studies including uncontrolled observations, large retrospective database analyses and controlled experimental studies, including randomised clinical trials, indicate that the different second-generation antipsychotics are associated with differing effects on glucose and lipid metabolism. These studies offer generally consistent evidence that clozapine and olanzapine treatment are associated with an increased risk of diabetes mellitus and dyslipidaemia. Inconsistent results, and a generally smaller effect in studies where an effect is reported, suggest limited if any increased risk for treatment-induced diabetes mellitus and dyslipidaemia during risperidone treatment, despite a comparable volume of published data. A similarly smaller and inconsistent signal suggests limited if any increased risk of diabetes or dyslipidaemia during quetiapine treatment, but this is based on less published data than is available for risperidone. The absence of retrospective database studies, and little or no relevant published data from clinical trials, makes it difficult to draw conclusions concerning risk for zotepine or amisulpride, although amisulpride appears to have less risk of treatment-emergent dyslipidaemia in comparison to olanzapine. With increasing data from clinical trials but little or no currently published data from large retrospective database analyses, there is no evidence at this time to suggest that ziprasidone and aripiprazole treatment are associated with an increase in risk for diabetes, dyslipidaemia or other adverse effects on glucose or lipid metabolism. In general, the rank order of risk observed for the second-generation antipsychotic medications suggests that the differing weight gain liability of atypical agents contributes to the differing relative risk of insulin resistance, dyslipidaemia and hyperglycaemia. This would be consistent with effects observed in nonpsychiatric samples, where risk for adverse metabolic changes tends to increase with increasing adiposity. From this perspective, a possible increase in risk would be predicted to occur in association with any treatment that produces increases in weight and adiposity. However, case reports tentatively suggest that substantial weight gain or obesity may not be a factor in up to one-quarter of cases of new-onset diabetes that occur during treatment. Pending further testing from preclinical and clinical studies, limited controlled studies support the hypothesis that clozapine and olanzapine may have a direct effect on glucose regulation independent of adiposity. The results of studies in this area are relevant to primary and secondary prevention efforts that aim to address the multiple factors that contribute to increased prevalence of type 2 diabetes mellitus and cardiovascular disease in populations that are often treated with second-generation antipsychotic medications.
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Affiliation(s)
- John W Newcomer
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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23
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Abstract
The atypical antipsychotics have been recognized to induce diabetes mellitus and ketoacidosis in the adult psychiatric population. This report notes the onset of weight gain, diabetes, and apparent ketosis in a prepubertal boy diagnosed with bipolar disorder and treated with olanzapine. The hyperglycemia rapidly normalized after discontinuation of the olanzapine. Within 2 years, the diabetes recurred. In spite of the normalization of blood-glucose levels, urine ketone tests remained positive and were explained by the fact that patients taking valproic acid may have a false-positive urine test for ketones. Regular monitoring of glucose should be considered in children and adolescents who gain weight while treated with atypical antipsychotics.
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Affiliation(s)
- Helen E Courvoisie
- Division of Child and Adolescent Psychiatry Division, Department of Psychiatry, Johns Hopkins Medical Institutions, Baltimore, MD 21287-3325, USA.
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Ader M, Kim SP, Catalano KJ, Ionut V, Hucking K, Richey JM, Kabir M, Bergman RN. Metabolic dysregulation with atypical antipsychotics occurs in the absence of underlying disease: a placebo-controlled study of olanzapine and risperidone in dogs. Diabetes 2005; 54:862-71. [PMID: 15734866 DOI: 10.2337/diabetes.54.3.862] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Atypical antipsychotics have been linked to weight gain, hyperglycemia, and diabetes. We examined the effects of atypical antipsychotics olanzapine (OLZ) and risperidone (RIS) versus placebo on adiposity, insulin sensitivity (S(I)), and pancreatic beta-cell compensation. Dogs were fed ad libitum and given OLZ (15 mg/day; n = 10), RIS (5 mg/day; n = 10), or gelatin capsules (n = 6) for 4-6 weeks. OLZ resulted in substantial increases in adiposity: increased total body fat (+91 +/- 20%; P = 0.000001) reflecting marked increases in subcutaneous (+106 +/- 24%; P = 0.0001) and visceral (+84 +/- 22%; P = 0.000001) adipose stores. Changes in adiposity with RIS were not different from that observed in the placebo group (P > 0.33). Only OLZ resulted in marked hepatic insulin resistance (hepatic S(I) [pre- versus postdrug]: 6.05 +/- 0.98 vs. 1.53 +/- 0.93 dl . min(-1) . kg(-1)/[microU/ml], respectively; P = 0.009). beta-Cell sensitivity failed to upregulate during OLZ (pre-drug: 1.24 +/- 0.15, post-drug: 1.07 +/- 0.25 microU . ml(-1)/[mg/dl]; P = 0.6). OLZ-induced beta-cell dysfunction was further demonstrated when beta-cell compensation was compared with a group of animals with adiposity and insulin resistance induced by moderate fat feeding alone (+8% of calories from fat; n = 6). These results may explain the diabetogenic effects of atypical antipsychotics and suggest that beta-cell compensation is under neural control.
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Affiliation(s)
- Marilyn Ader
- Keck School of Medicine, Department of Physiology and Biophysics, University of Southern California, MMR 624, 1333 San Pablo St., Los Angeles, CA 90033, USA.
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Abstract
This retrospective study compared the prevalence of diabetes mellitus/hyperglycemia between patients receiving treatment with clozapine (n = 24) and patients receiving treatment with depot (n = 27) neuroleptics in a Department of Veterans Affairs outpatient mental health clinic in the Mid-Atlantic region. Of the clozapine cases without a history of diabetes/hyperglycemia, 27.7% developed diabetes after initiation of clozapine. There were no new cases of diabetes/hyperglycemia in the depot group after initiation of depot neuroleptic. All patients receiving neuroleptic treatment should be monitored for changes in weight, lipid, and glucose levels so that appropriate preventive and therapeutic measures can be promptly initiated.
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Affiliation(s)
- Marilyn J Miller
- Maryland Veterans Affairs Health Care System, Mental Health Clinic, Perry Point, MD 21902, USA.
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Lambert BL, Chou CH, Chang KY, Tafesse E, Carson W. Antipsychotic exposure and type 2 diabetes among patients with schizophrenia: a matched case-control study of California Medicaid claims. Pharmacoepidemiol Drug Saf 2005; 14:417-25. [PMID: 15786516 DOI: 10.1002/pds.1092] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE To examine the risk of developing type 2 diabetes mellitus among people with schizophrenia exposed to atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone) compared to those exposed to conventional antipsychotics. METHODS A matched case-control design was used to examine California Medicaid beneficiaries. Cases developed diabetes subsequent to being diagnosed with schizophrenia (ICD-9295), were 18 years or older, and were exposed to at least one antipsychotic medication at some point during the 12 weeks preceding diabetes diagnosis. Diabetes was defined by diagnostic claim (ICD-9250) or prescription for antidiabetic agents. A total of 3663 cases were matched to 14 523 non-diabetic controls (people with schizophrenia matched on gender and age +/-5 years). All had to be continuously eligible for benefits during the 12-week period preceding diabetes onset in the case. Conditional logistic regression modeled the risk of exposure, controlling for age, ethnicity, and exposure to selected concomitant medications. Analyses were repeated with 24- and 52-week exposure windows. RESULTS Using a 12-week exposure window, olanzapine (OR = 1.36, 95%CI 1.20-1.53), clozapine (OR = 1.34, 95%CI 1.16-1.55), and combination atypical therapy (OR = 1.58, 95%CI 1.33-1.88), but not risperidone or quetiapine, were associated with increased odds of developing diabetes compared to conventional antipsychotics. Changing to a 24-week exposure window, the risks were: olanzapine (OR = 1.38, 95%CI 1.22-1.56), clozapine (OR = 1.32, 95%CI 1.14-1.53), or combinations (OR = 1.54, 95%CI 1.29-1.84). With a 52-week exposure window, the risks were: olanzapine (OR = 1.41, 95%CI 1.24-1.60), clozapine (OR = 1.41, 95%CI 1.21-1.65), combinations (OR = 1.58, 95%CI 1.31-1.90). Risk for olanzapine increased with dose. Hispanic, African American, and unknown ethnicity were significant risks for development of type 2 diabetes as was exposure to selected concomitant medications. CONCLUSIONS Exposure to olanzapine or clozapine is associated with a 34-41% increase in the developing of type 2 diabetes among California Medicaid recipients with schizophrenia. Prospective, randomized trials are needed to confirm these retrospective, observational findings.
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Affiliation(s)
- Bruce L Lambert
- Department of Pharmacy Administration, University of Illinois, Chicago, IL 60612-7231, USA.
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Sacchetti E, Turrina C, Parrinello G, Brignoli O, Stefanini G, Mazzaglia G. Incidence of diabetes in a general practice population: a database cohort study on the relationship with haloperidol, olanzapine, risperidone or quetiapine exposure. Int Clin Psychopharmacol 2005; 20:33-7. [PMID: 15602114 DOI: 10.1097/00004850-200501000-00007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study aimed to estimate the incidence of diabetes in general practice patients who were treated with haloperidol, olanzapine, risperidone or quetiapine monotherapy and in subjects who were not exposed to antipsychotics. The design was a retrospective, up to 2 years, cohort study, with age-, sex- and length of observation-matching between subjects who were exposed and not exposed to antipsychotic drugs. Data were taken from the Health Search database, which contains information from 550 Italian general practitioners. Participants comprised 2,071 subjects taking haloperidol, 266 taking olanzapine, 567 taking risperidone and 109 taking quetiapine, in addition to 6,026 age- and sex-matched subjects who were not using antipsychotic drugs during the period of observation. Inclusion was limited to initially non-diabetic and antipsychotic drug-free individuals. The main outcome measure was the incidence of drug-treated diabetes. After age and sex correction by Cox regression analysis, the four groups treated with antipsychotics significantly differed from untreated subjects in hazard ratios for diabetes. The ratios for the haloperidol, olanzapine, risperidone and quetiapine groups were 12.4 (95% confidence interval 6.3-24.5), 20.4 (6.9-60.3), 18.7 (8.2-42.8) and 33.7 (9.2-123.6), respectively, with no significant differences when compared to each other.
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Farwell WR, Stump TE, Wang J, Tafesse E, L'Italien G, Tierney WM. Weight gain and new onset diabetes associated with olanzapine and risperidone. J Gen Intern Med 2004; 19:1200-5. [PMID: 15610330 PMCID: PMC1492596 DOI: 10.1111/j.1525-1497.2004.40126.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess whether newer antipsychotic medications are associated with weight gain and development of diabetes. DESIGN Retrospective cohort study. SETTING Data from a comprehensive electronic medical record serving an urban public hospital and a citywide network of mental health clinics. PATIENTS/PARTICIPANTS Three thousand one hundred fifteen patients at least 18 years old who were prescribed a single antipsychotic drug for at least 1 year. METHODS We identified independent predictors of significant weight gain (> or =7%) and new onset of diabetes mellitus in the first year of antipsychotic drug treatment, using logistic regression adjusted for demographic characteristics, obesity, preexisting psychiatric diagnoses, alcohol and drug abuse, number of primary care, psychiatric clinic, and emergency department visits, and pretreatment weight. MEASUREMENTS AND MAIN RESULTS Twenty-five percent of patients taking older phenothiazines developed significant weight gain in the first year of treatment compared to 40% of the patients taking olanzapine (adjusted odds ratio [OR], 2.8; 95% confidence interval [CI], 1.7 to 4.6; P <.0001) and 37% of patients taking risperidone (adjusted OR, 2.3; 95% CI, 1.5 to 3.4; P <.0001). New diabetes developed in 3% of patients taking older phenothiazines was new onset diabetes compared to 8.0% of patients taking olanzapine (adjusted OR, 1.9; 95% CI, 1.1 to 3.3; P=.03) and 3.5% of patients taking risperidone (adjusted OR, 0.7; 95% CI, 0.4 to 1.4; P=.3). No association was found between significant weight gain and developing diabetes (adjusted OR, 0.7; 95% CI, 0.4 to 1.4; P=.4). CONCLUSIONS Olanzapine and risperidone use was associated with gaining weight in the first year, but only olanzapine was associated with developing diabetes mellitus.
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Pijl H. Reduced dopaminergic tone in hypothalamic neural circuits: expression of a "thrifty" genotype underlying the metabolic syndrome? Eur J Pharmacol 2004; 480:125-31. [PMID: 14623356 DOI: 10.1016/j.ejphar.2003.08.100] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The thrifty genotype hypothesis postulates that the genetically determined ability to grow obese and insulin resistant in times of food abundance confers a survival advantage in times of famine. Obviously, this ability poses a major health threat in modern times, where food is always available in large quantities. In the last 10-15 years, many genes encoding pathways that orchestrate energy balance and fuel flux have been discovered. This paper summarizes the evidence that diminished dopaminergic tone in hypothalamic nuclei contributes to the "thrifty" genotype/phenotype. Reduced dopaminergic neurotransmission in the suprachiasmatic nucleus of seasonally obese animals appears to drive noradrenalin and NPY mediated transmissions in other nuclei to induce the obesity syndrome at the appropriate time of year. Treatment with dopamine D(2) receptor agonists can fully reverse the metabolic syndrome in these animals. Similar mechanisms are operative in non-seasonal obese animal models. In man, treatment with dopamine D(2) receptor antagonists induces obesity and type 2 diabetes mellitus, whereas dopamine D(2) receptor activation ameliorates the metabolic profile in obese nondiabetic and diabetic humans. Various loss of function mutations of the dopamine D(2) receptor gene are associated with overweight in humans. In concert, the data support the notion that diminution of dopaminergic (dopamine D(2) receptor mediated) transmission in relevant hypothalamic nuclei sets the stage for efficient partitioning of ingested nutrients to contribute to a phenotype that is not so thrifty anymore.
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Affiliation(s)
- Hanno Pijl
- Department of Internal Medicine, Leiden University Medical Center, C1-R39, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Abstract
AIMS To determine the prevalence of diabetes mellitus and its possible causes and to assess its control in a high secure hospital. METHODS A cross sectional survey and a prospective cohort study were conducted. The cross sectional survey included 408 patients admitted under the Mental Health Act, and the prospective study included 22 patients with known diabetes followed up for 24 months. The outcome measures evaluated were drug treatment, status of microvascular and macrovascular complications, glycated haemoglobin, and body mass index. RESULTS In the cross sectional survey, 35 out of 408 patients (8.6%; 95% confidence interval 5.9% to 11.3%) had known diabetes, and all of these had type 2 diabetes. Obesity, cigarette smoking, schizophrenia, and antipsychotic drug use were frequent, and weight gain was common after hospital admission. Glycaemic control was variable, and, although a majority of patients were above recommended treatment targets, control remained stable over the follow up period. CONCLUSIONS Type 2 diabetes was common in this hospital. Both its prevalence and the suboptimal glycaemic control in some patients probably relate to sedentary life, dietary factors, smoking, and perhaps widespread use of antipsychotic drugs. However, regular multidisciplinary input enabled most patients to maintain relatively stable glycaemic control, with good control of blood pressure and lipids, at levels similar to those seen in community and hospital diabetic clinics. Further modification of lifestyle risk factors is probably needed to reduce the prevalence and impact of diabetes in this patient group.
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Affiliation(s)
- I A MacFarlane
- Department of Diabetes and Endocrinology, University Hospital Aintree, Liverpool, UK.
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Palenzona S, Meier PJ, Kupferschmidt H, Rauber-Luethy C. The Clinical Picture of Olanzapine Poisoning with Special Reference to Fluctuating Mental Status. ACTA ACUST UNITED AC 2004; 42:27-32. [PMID: 15083933 DOI: 10.1081/clt-120028741] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Olanzapine is an atypical antipsychotic drug that is increasingly used in intentional drug overdoses. Although acute olanzapine overdose is predominantly associated with anticholinergic symptoms and central nervous system depression, miosis and unpredictable fluctuations between somnolence/coma and agitation/ aggression have been suggested as typical signs of olanzapine intoxication in single case reports. AIMS To confirm the suggestion that fluctuating central nervous system changes and miosis are characteristic signs of olanzapine intoxication. To estimate the dose-response relationship as a guide for the provision of optimal management of olanzapine intoxicated patients. METHODS Retrospective analysis of all well-documented cases of olanzapine intoxication reported to the Swiss Toxicological Information Centre between January 1997 and October 2001. Inclusion criteria for detailed analysis were patient age > or = 16 yr, acute olanzapine monointoxication, ingested dose > 20 mg, and a causal relationship between olanzapine overdose and clinical effects. The Poisoning Severity Score of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT) assessed the intoxication severity. RESULTS Out of a total of 131 cases of olanzapine overdose, 26 cases fulfilled the inclusion criteria. The ingested olanzapine doses ranged from 30 to 840 mg. The most frequent findings were somnolence (77%), agitation (42%), and miosis (31%). The Poisoning Severity Score was "minor" in 14 (54%), "moderate" in 11 (42%), and "severe" in 1 (4%) patients. Nine patients (35% of all patients) with moderate olanzapine poisoning (120-840 mg) showed unpredictable fluctuations between somnolence and agitation. Five of these patients also demonstrated marked miosis. All patients recovered within 48h. One patient with severe poisoning (560 mg) had coma and convulsions. Moderate (and severe) symptoms occurred only at ingested doses above 120 mg. There was a statistically significant association between increasing ingested olanzapine doses and poisoning severity. CONCLUSIONS Although olanzapine is tolerated relatively well in acute overdose, unpredictable and transient fluctuations between central nervous system depression and agitation, frequently associated with miosis, appear to be characteristic findings in moderate to high olanzapine overdoses. They are transient in nature and require careful clinical monitoring but rarely require specific therapeutic interventions.
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Abstract
Diabetes and mental disorders are common chronic illnesses in the United States. Recently, the introduction of a new class of atypical antipsychotic medications has been a major treatment advance for patients with mental disorders. Because of increased use of atypical antipsychotic medications, new and unanticipated side effects have often appeared. Treatment-emergent diabetes has been described for conventional and atypical antipsychotics. People with schizophrenia may be at increased risk for type 2 diabetes because of the side effects of antipsychotic medication, underlying predisposition, and less healthy lifestyles.
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Affiliation(s)
- Roopa Sathyaprakash
- VA San Diego Health Care System, 2045 W El Camino Real, #126, Mountain View, CA 94040, USA.
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Abstract
Adverse metabolic effects, such as diabetes mellitus, lipid abnormalities and weight gain, have increasingly been recognised with the use of the newer, so-called atypical antipsychotic drugs. This article reviews the current literature in the field and attempts to answer the question of whether the atypical antipsychotics differ in their effects on glucose-insulin homeostasis and lipid metabolism. It also addresses how then to manage the use of the atypical antipsychotics that do interfere with these metabolic systems. Differences in effects of atypical antipsychotics on leptin levels are also summarised and put into context; bodyweight gain associated with atypical antipsychotics is reviewed elsewhere. In summary, there are no large controlled trials published quantifying the prevalence of adverse effects on glucose-insulin homeostasis and lipid metabolism in patients receiving atypical antipsychotics. Nevertheless, the published articles and case reports reviewed in this article give a fairly good view of those adverse effects occurring with clozapine, olanzapine and risperidone, whereas little data are available regarding quetiapine, ziprasidone and zotepine, and no data exist for amisulpride and aripiprazole. Estimated rankings of the atypical agents, based on the available literature, show that the relative risk of glucose intolerance/diabetes mellitus, hyperlipidaemia and hyperleptinaemia is highest for clozapine and olanzapine, moderately high for quetiapine, rather low for risperidone and lowest for ziprasidone. Since adverse metabolic effects of atypical antipsychotics may have a negative influence on both the antipsychotic treatment outcome as well as the physical health of the patient, these effects have to be recognised and adequately managed. In this review, recommendations for prevention and treatment of the adverse metabolic effects are outlined.
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Affiliation(s)
- Kristina Melkersson
- Psychiatric Polyclinic, Sollentuna Hospital, Nytorpsvägen 10-12, SE-191 35 Sollentuna, Sweden.
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Barceló Colomer ME, Mateu Ramon MC, Miralles Belda V, Moretó Reventós A. Olanzapina y descompensación diabética: a propósito de un caso. Aten Primaria 2004; 34:58-9. [PMID: 15207204 PMCID: PMC7688674 DOI: 10.1016/s0212-6567(04)79455-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Feldman PD, Hay LK, Deberdt W, Kennedy JS, Hutchins DS, Hay DP, Hardy TA, Hoffmann VP, Hornbuckle K, Breier A. Retrospective Cohort Study of Diabetes Mellitus and Antipsychotic Treatment in a Geriatric Population in the United States. J Am Med Dir Assoc 2004. [DOI: 10.1016/s1525-8610(04)70042-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gianfrancesco F, White R, Wang RH, Nasrallah HA. Antipsychotic-induced type 2 diabetes: evidence from a large health plan database. J Clin Psychopharmacol 2003; 23:328-35. [PMID: 12920407 DOI: 10.1097/01.jcp.0000085404.08426.3a] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Case evidence suggests that some of the atypical antipsychotics may induce type 2 diabetes. The objective of this study was to evaluate the association of antipsychotic treatment with type 2 diabetes in a large health plan database. Claims data for patients with psychosis within a health plan of nearly 2 million members were analyzed using logistic regression. Frequencies of newly treated type 2 diabetes in patients untreated with antipsychotics and among patients treated with quetiapine, risperidone, olanzapine, and conventional antipsychotics were compared. Based on exposure measured in months of antipsychotic treatment, quetiapine and risperidone patients had estimated odds of receiving treatment for type 2 diabetes that were lower than those of patients untreated with antipsychotics (not statistically significant); patients treated with conventional antipsychotics had estimated odds that were virtually equivalent to those of patients untreated with antipsychotics; olanzapine alone had odds that were significantly greater than those of patients untreated with antipsychotics (P = 0.0247). Odds ratios based on 8 months of screening for pre-existing type 2 diabetes and assuming 12 months of antipsychotic treatment were: risperidone = 0.660 (95% CI 0.311-1.408); olanzapine = 1.426 (95% CI 1.046-1.955); quetiapine = 0.976 (95% CI 0.422-2.271); and conventional antipsychotics = 1.049 (95% CI 0.688-1.613). Case reports, prospective trials, and other retrospective studies have increasingly implicated olanzapine and clozapine as causing or exacerbating type 2 diabetes. Few have implicated risperidone while evidence on quetiapine has been limited. This study supports earlier findings on risperidone versus olanzapine and builds evidence on quetiapine. Additional studies are needed to evaluate the association of antipsychotic treatment with type 2 diabetes.
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Fuller MA, Shermock KM, Secic M, Grogg AL. Comparative study of the development of diabetes mellitus in patients taking risperidone and olanzapine. Pharmacotherapy 2003; 23:1037-43. [PMID: 12921249 DOI: 10.1592/phco.23.8.1037.32876] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A growing body of literature suggests that certain atypical antipsychotics, especially olanzapine and clozapine, may induce glucoregulatory dysfunction. We assessed the differences in risk of developing diabetes mellitus during treatment with olanzapine and risperidone by using patients treated with haloperidol and fluphenazine as control subjects in whom we would not expect to see an increased risk. METHODS We conducted a retrospective analysis of the Veteran's Integrated Service Network 10 Veterans Affairs (VA) database. Data for patients receiving olanzapine, risperidone, haloperidol, or fluphenazine from January 1, 1997-December 31, 2000, were included. Diabetes was defined as any health system encounter associated with the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis for diabetes (250.xx) or prescription for a hypoglycemic agent. Data of patients with markers for diabetes within 1 year before their index date, female patients, racial groups other than Caucasian or African-American, and patients receiving clozapine were not analyzed. We performed a Cox regression, with antipsychotic therapy as a time-dependent covariate. Other covariates considered for inclusion in the final model were number of days supply of antipsychotic drug, age, race, psychiatric diagnoses, substance abuse, lithium, valproic acid, and other typical or atypical antipsychotic agents. RESULTS Data for 5837 patients were analyzed. Overall rate of developing diabetes in the study population was 6.3% (368 of 5837 patients). Olanzapine therapy was associated with a significantly higher risk of development of diabetes compared with risperidone (hazard ratio [HR] 1.37, 95% confidence interval 1.06-1.76, p=0.016) while controlling for race, age, diagnosis, substance abuse, lithium, valproic acid, and other atypical antipsychotic agents. No differences in the rate of developing diabetes were detected between fluphenazine and risperidone (HR 1.11, p=0.69), or haloperidol and risperidone (HR 0.89, p=0.41). CONCLUSIONS Olanzapine was associated with a 37% (HR 1.37) increased risk of development of diabetes compared with risperidone in a VA population, even after adjusting for other factors associated with the development of diabetes and temporal exposure to study drug. Because of limitations associated with database research, prospective studies should be conducted to corroborate these findings.
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Affiliation(s)
- Matthew A Fuller
- Pharmacy Service, Louis Stokes Cleveland VAMC, Brecksville, Ohio 44141-3204, USA
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Abstract
Patients with schizophrenia are more likely than the general population to develop diabetes, which contributes to a high risk of cardiovascular complications; individuals with schizophrenia are two to three times more likely to die from cardiovascular disease than the general population. The risk of diabetes, and hence cardiovascular disease, is particularly increased by some of the new atypical antipsychotic drugs. Individuals taking an atypical antipsychotic drug, particularly younger patients under 40 years of age (odds ratio 1.63, 95% CI 1.23-2.16), represent an underrecognized group at high risk of type 2 diabetes. The mechanisms responsible for antipsychotic-induced diabetes remain unclear. Hypotheses include these drugs' potential to cause weight gain, possibly through antagonism at the H(1), 5-HT(2A), or 5-HT(2C) receptors. Other mechanisms independent of weight gain lead to elevation of serum leptin and insulin resistance. Patients with psychoses have difficulties with diet and lifestyle interventions for diabetes and weight management. If hyperglycemia develops, withdrawal from antipsychotic medication will often be inappropriate, and a change to an atypical antipsychotic drug with lower diabetogenic potential should be considered, especially in younger patients. Management of psychoses should routinely include body weight and blood glucose monitoring and steps to promote exercise and minimize weight gain. Careful collaboration between the psychiatric and diabetology teams is essential to minimize the risk of diabetes in patients taking atypical antipsychotic medication and for effective management when it develops. This collaboration will also help minimize the already high risk of cardiovascular disease in individuals with schizophrenia.
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Elovic EP, Lansang R, Li Y, Ricker JH. The use of atypical antipsychotics in traumatic brain injury. J Head Trauma Rehabil 2003; 18:177-95. [PMID: 12802226 DOI: 10.1097/00001199-200303000-00008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of antipsychotic medication in treating individuals with traumatic brain injury (TBI) has been controversial. Much of the caution derives from animal studies (and limited human data) with regard to typical antipsychotics. Of note, however, is that similar assumptions have been made about the newer generation of atypical antipsychotics as well. Because these agents have different mechanisms of action as well as different neurotransmitter targets, this may very well be unwarranted. In this article, mechanisms of action of typical and atypical antipsychotics are discussed, with particular attention paid to their use in TBI. Indications and contraindications are presented, and recommendations are made for the responsible prescribing of antipsychotic medications after TBI.
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Affiliation(s)
- Elie Paul Elovic
- Traumatic Brain Injury Research, Kessler Medical Rehabilitation Research Education Corporation (KMRREC), West Orange, NJ, USA
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40
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Abstract
Diabetes or hyperglycemia associated with the use of atypical anti-psychotic agents is a subject of growing concern among health care providers and the patients who use the drugs. Although much attention has been relegated to this topic in the mental health literature, there has been little attention devoted to it in the diabetes literature. The purpose of this report is to review the problem of diabetes mellitus associated with atypical anti-psychotic use from an endocrinology perspective. This paper will specifically present (a) a review of the increased prevalence of diabetes in the setting of schizophrenia, (b) a compilation and critical assessment of the existing publications that have documented the association of hyperglycemia and atypical anti-psychotic use, (c) a discussion of the potential mechanisms through which antipsychotics may lead to disturbances in glucose homeostasis, and (d) recommendations for the effective monitoring and treatment of affected patients.
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Affiliation(s)
- Clifford Clark
- Department of Medicine/Endocrinology, University Services, MSC10 5550, UNM HSC, University of New Mexico, Albuquerque, NM 87131, USA
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41
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Waldman JC, Yaren S. Atypical antipsychotics and glycemia: a case report. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2002; 47:686-7. [PMID: 12355686 DOI: 10.1177/070674370204700721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Koro CE, Fedder DO, L'Italien GJ, Weiss SS, Magder LS, Kreyenbuhl J, Revicki DA, Buchanan RW. Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. BMJ 2002; 325:243. [PMID: 12153919 PMCID: PMC117636 DOI: 10.1136/bmj.325.7358.243] [Citation(s) in RCA: 284] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To quantify the association between olanzapine and diabetes. DESIGN Population based nested case-control study. SETTING United Kingdom based General Practice Research Database comprising 3.5 million patients followed between 1987 and 2000. PARTICIPANTS 19 637 patients who had been diagnosed as having and treated for schizophrenia. 451 incident cases of diabetes were matched with 2696 controls. MAIN OUTCOME MEASURES Diagnosis and treatment of diabetes. RESULTS Patients taking olanzapine had a significantly increased risk of developing diabetes than non-users of antipsychotics (odds ratio 5.8, 95% confidence interval 2.0 to 16.7) and those taking conventional antipsychotics (4.2, 1.5 to 12.2). Patients taking risperidone had a non-significant increased risk of developing diabetes than non-users of antipsychotics (2.2, 0.9 to 5.2) and those taking conventional antipsychotics (1.6, 0.7 to 3.8). CONCLUSION Olanzapine is associated with a clinically important and significant increased risk of diabetes.
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Affiliation(s)
- Carol E Koro
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore, MD 21201, USA
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43
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Abstract
STUDY OBJECTIVE To explore the clinical characteristics of hyperglycemia in patients treated with olanzapine. DESIGN Retrospective, epidemiologic survey of spontaneously reported adverse events related to olanzapine therapy SETTING Government-affiliated drug evaluation center. PATIENTS Two hundred thirty-seven patients with olanzapine-associated diabetes or hyperglycemia. INTERVENTION One hundred ninety-six cases from January 1994-May 15, 2001, were identified with the United States Food and Drug Administration's MedWatch Drug Surveillance System, and 41 cases published through May 15, 2001, were identified with MEDLINE or through meeting abstracts. MEASUREMENTS AND MAIN RESULTS Of the 237 cases, 188 were new-onset diabetes, 44 were exacerbations of preexistent disease, and 5 could not be classified. Mean patient age for newly diagnosed cases was 40.7+/-12.9 years and male:female ratio was 1.8. Seventy-three percent of all cases of hyperglycemia appeared within 6 months of start of olanzapine therapy. Eighty patients had metabolic acidosis or ketosis, 41 had glucose levels of 1000 mg/dl or greater, and 15 patients died. When olanzapine was discontinued or the dosage decreased, 78% of patients had improved glycemic control. Hyperglycemia recurred in 8 of 10 cases with rechallenge. CONCLUSIONS Number of reports, temporal relationship to start of olanzapine therapy, relatively young age, and improvement on drug withdrawal suggest that olanzapine may precipitate or unmask diabetes in susceptible patients.
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Affiliation(s)
- Elizabeth A Koller
- Division of Metabolic and Endocrine Drug Products, Center for Drug Evaluation and Review, Food and Drug Administration, Rockville, Maryland, USA
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Straker D, Mendelowitz A, Karlin L. Near fatal ketoacidosis with olanzapine treatment. PSYCHOSOMATICS 2002; 43:339-40. [PMID: 12189265 DOI: 10.1176/appi.psy.43.4.339] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE To provide evidence that olanzapine can cause glucose dysregulation by a mechanism other than weight gain. METHOD I report a case of a diabetic patient who developed glucose dysregulation soon after initiation of olanzapine treatment, occurring in the absence of weight gain. I compare this case to previous case reports. RESULTS Our patient developed persistent hyperglycaemia within 3 weeks of initiating treatment with olanzapine. Weight recorded just prior to commencement and soon after discontinuation of olanzapine were not significantly different. CONCLUSION Controlled studies are necessary to elucidate the mechanism by which olanzapine can cause dysregulation of glucose homeostasis, and to develop guidelines for the use of olanzapine in patients with known diabetes as well as in patients with risk factors for diabetes.
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Affiliation(s)
- G Ramankutty
- Auckland Regional Psychiatric Registrar Training Centre, Auckland, New Zealand.
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46
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Melkersson K, Hulting AL. Recovery from new-onset diabetes in a schizophrenic man after withdrawal of olanzapine. PSYCHOSOMATICS 2002; 43:67-70. [PMID: 11927762 DOI: 10.1176/appi.psy.43.1.67] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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48
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Abstract
Clozapine is a potent antipsychotic agent that has been marketed since 1990. Several published reports of diabetes mellitus occurring with clozapine therapy have appeared during the past 5 years. Because the risk and characteristics of clozapine-associated diabetes mellitus remain unclear, we conducted a descriptive epidemiologic study of spontaneous adverse event reports of hyperglycemia occurring in clozapine-treated patients. The Food and Drug Administration MedWatch surveillance program was queried (January 1990 through February 2001), and the results were pooled with published cases. Parameters assessed included documentation of diabetes, clinical severity, new-onset diabetes versus exacerbation of preexisting disease, demographic characteristics of patients, time to onset of hyperglycemia, and effect of drug discontinuation and rechallenge. We identified 384 reports. Of these, new-onset diabetes was diagnosed definitively in 242 patients, and 54 patients had exacerbation of preexisting disease. The mean (+/- SD) age was 40 +/- 12 years (range, 13 to 77). The male:female ratio was 2:0. Most cases appeared within 6 months of initiating clozapine therapy. One patient developed diabetes following a single 500-mg dose. There were 80 cases of metabolic acidosis or ketosis. Twenty-five patients died during hyperglycemic episodes. Forty-six patients had improved glycemic control after discontinuation or dose reduction of the drug.A causal relationship between clozapine and diabetes is suggested by the number of reports, the temporal relation to clozapine initiation, the relatively young age of the affected patients, and the prompt reversibility on withdrawal of the drug in some patients. The severity of reported cases ranged from mild glucose intolerance to diabetic ketoacidosis or hyperosmolar coma.
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Affiliation(s)
- E Koller
- Center for Drug Evaluation and Research, Food and Drug Administration, Rockville, Maryland 20857, USA
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Kennedy JS, Bymaster FP, Schuh L, Calligaro DO, Nomikos G, Felder CC, Bernauer M, Kinon BJ, Baker RW, Hay D, Roth HJ, Dossenbach M, Kaiser C, Beasley CM, Holcombe JH, Effron MB, Breier A. A current review of olanzapine's safety in the geriatric patient: from pre-clinical pharmacology to clinical data. Int J Geriatr Psychiatry 2001; 16 Suppl 1:S33-61. [PMID: 11748788 DOI: 10.1002/1099-1166(200112)16:1+<::aid-gps571>3.0.co;2-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Olanzapine (OLZ) is unique among currently available antipsychotic medications in its antagonism of a range of receptor systems including dopamine, norepinephrine, serotonin, acetylcholine, and histamine. Olanzapine's mechanistic complexity provides a broad efficacy profile in patients with schizophrenia and acute, pure or mixed mania. Patients experience symptomatic relief of mania, anxiety, hallucinations, delusions, and agitation/aggression and reduced depressive, negative, and some cognitive symptoms. This paper will review the safety profile of OLZ, focusing on the elderly, where data are available. METHOD Preclinical and clinical studies of OLZ are reviewed, with emphasis on its possible effects on the cholinergic system and the histamine H(1) receptor. Weight change and related metabolic considerations, cardiac and cardiovascular safety, and motor function during treatment with OLZ are also reviewed. RESULTS AND CONCLUSION In vitro receptor characterization methods, when done using physiologically relevant conditions allow accurate prediction of the relatively low rate of anticholinergic-like adverse events, extrapyramidal symptoms, and cardiovascular adverse events during treatment with OLZ. Currently available clinical data suggest olanzapine is predictably safe in treating adult patients of any age with schizophrenia and acute bipolar mania, as well as in treatment of patients with some types of neurodegenerative disorders.
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Affiliation(s)
- J S Kennedy
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana 46285, USA
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Abstract
OBJECTIVE To report the case of a patient taking olanzapine who developed diabetic ketoacidosis (DKA). CASE SUMMARY A 46-year-old African American woman with no previous history of diabetes mellitus was admitted to the hospital and subsequently diagnosed with DKA and acute pancreatitis. The patient had been taking olanzapine, valproic acid, carbamazepine, hydrochlorothiazide/triamterene, and conjugated estrogens prior to admission. Olanzapine was the last medication added to the regimen. In addition to clinicians treating the DKA with appropriate interventions, olanzapine (due to possible association with hyperglycemia and DKA) as well as valproic acid (due to possible association with pancreatitis) were discontinued from the medication regimen. The patient was discharged home and her most recent glycosylated hemoglobin and fasting glucose concentrations have been within the normal range. DISCUSSION Atypical antipsychotics, such as olanzapine, have been associated with hyperglycemia and possibly DKA. We believe that this occurred in our patient who had no previous history of diabetes mellitus. Possible mechanisms of action and potential confounding variables are discussed. CONCLUSIONS Clinicians should monitor blood glucose concentrations periodically in patients taking olanzapine, especially in those patients with risk factors for diabetes mellitus.
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Affiliation(s)
- K R Ragucci
- Departments of Pharmacy Practice and Family Medicine, Medical University of South Carolina, 295 Calhoun St., PO Box 250192, Charleston, SC 29425-0001, USA.
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