Weight development in patients treated with risperidone: a 5-year naturalistic study

Growth and weight status of Brazilian children with autism spectrum disorders: A mixed longitudinal study

OBJECTIVE

This study examined the growth status and physical development of Brazilian children with autism spectrum disorders from 4 to 15 years of age. Furthermore, it was examined whether variation in growth patterns and weight status was influenced by the use of psychotropic medications.

METHODS

One-hundred and twenty children aged 3.6-12.1 years at baseline (average=7.2 years, SD=2.3 years) diagnosed with autism spectrum disorders were measured on three repeated occasions across a 4-year period. Stature, body mass, and body mass index were considered. Bayesian multilevel modeling was used to describe the individual growth patterns.

RESULTS

Growth in stature was comparable to the age-specific 50th percentile for Centers for Disease Control and Prevention reference data until approximately 8 years, but a substantial decrease in growth rate was observed thereafter, reaching the age-specific 5th percentile at 15 years of age. Both body mass and body mass index values were, on average, higher than both the Brazilian and Centers for Disease Control and Prevention age-specific 95th percentile reference until 8 years, but below the 50th specific-age percentile at the age of 15 years.

CONCLUSIONS

Brazilian boys with autism spectrum disorders between 4 and 15 years appear to have impaired growth in stature after 8-9 years of age, likely impacting pubertal growth. A high prevalence of overweight and obesity was observed in early childhood, although a trend of substantial decrease in body mass and body mass index was apparent when children with autism spectrum disorders entered the years of pubertal development.

Prolactin and human weight disturbances: A puzzling and neglected association

Weight gain at the outset of prolactinomas in many women is well documented. Yet, this symptom is absent from the clinical descriptions of the disease in textbooks and reviews. This omission is almost certainly due to the absence of a physiological explanation for the phenomenon, as prolactin is not a recognized fat promoting hormone. In this review we present the clinical evidence for a relationship between prolactin and fat accumulation and address some possible mechanisms involved. We put forward the hypothesis that prolactin is a component of a neuroendocrine program - maternal subroutine - aimed at optimizing the care of the young through the production of milk, promotion of maternal behavior and increase in the metabolic efficiency of the mother. These adaptations can enable her to face the extraordinary metabolic expenses of pregnancy and nursing, especially during times of suboptimal environmental conditions. We emphasize the uniqueness of prolactin in that it is a hormone that is tonically inhibited and which has its major effects on the regulation of an inter-individual (the mother - offspring dyad), rather than an intra-individual, system. This approach opens a window to consider the possibility of external events as regulators of this system. It also allows addressing a variety of hitherto unexplained findings reported in the literature. Examples include: association of prolactinomas with paternal deprivation and with stressful life events; pseudocyesis; acute life event-driven episodes of galactorrhea; episodes of rapid weight gain following a life event; prolactin surges (without associated cortisol surges) following some psychological stresses.

No differences in olanzapine- and risperidone-related weight gain between women and men: a meta-analysis of short- and middle-term treatment

OBJECTIVE

A plethora of data deriving from single studies as well as meta-analyses demonstrates that weight gain is associated with the exposure to the majority of antipsychotics (AP). However, potential sex differences have widely evaded the attention of AP treatment trials. It is hypothesised that female patients gain more weight compared with male patients due to their enhanced susceptibility to adverse drug reactions.

METHOD

A meta-analysis was conducted using clinical trials of AP that reported weight change separately for female and male patients. Duration of AP use was stratified in four categories: <6 weeks, 6-16 weeks, 16-38 weeks and >38 weeks. Forest plots were generated for men and women separately, stratified by AP as well as by duration of use. Sex differences were tested by performing meta-regression.

RESULTS

Data of 26 studies were used in the present analysis because sufficient data were available only for olanzapine, risperidone and the no-medication group. Both female and male patients showed considerable weight gain after switch or initiate of olanzapine or risperidone, but meta-regression analyses did not show significant sex differences.

CONCLUSION

The present meta-analysis revealed that sex differences in AP-related weight gain have been under investigated hampering the detection of sex-specific patterns. In chronic patients switching to olanzapine or risperidone receiving short-or middle-term treatment, AP were associated with weight gain in both sex subgroups and no significant differences were reported.

[Hyperprolactinemia associated with neuroleptic treatment: clinical characteristics and an impact on sexual function]

AIM

To study clinical characteristics of antipsychotic-induced hyperprolactinemia (AIH) and an impact of AIH on sexual function in patients with mental disorders treated with neuroleptics for a long time.

MATERIAL AND METHODS

A cross-sectional study of 244 consecutive psychiatric in-patients (F/M=140/104) with mental disorders currently taking antipsychotics was carried out. The patients were screened for serum prolactin, sex hormones and gonadotropin levels. The UKU Side effects rating scale (UKU) was used to assess side-effects. For assessment of sexual dysfunction, the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ) was administered.

RESULTS AND CONCLUSION

Asymptomatic AIH was found in 16% of females and in 37% of males. AIH caused menstrual disorders (oligomenorrhea and amenorrhea), galactorrhea in females. AIH was associated with libido decrease and life quality impairment due to sexual dysfunctions in patients of both genders. AIH was associated with orgasm delay and vaginal dryness during sexual intercourse in females. In men, AIH was associated with erectile dysfunction. In contrast to pituitary tumor and idiopathic hyperprolactinemia, there was no association between AIH and weight gain and/or obesity, and hypogonadism in patients of both genders.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

Randomized controlled trial comparing changes in serum prolactin and weight among female patients with first-episode schizophrenia over 12 months of treatment with risperidone or quetiapine

Background

Increased serum prolactin and weight gain are common side effects of atypical antipsychotics but few studies have assessed the long-term pattern of these adverse effects.

Aim

Compare the effects of risperidone and quetiapine on serum prolactin and weight over 12 months of treatment among female patients with first-episode schizophrenia.

Methods

Eighty female inpatients with first-episode schizophrenia were randomly assigned to receive risperidone (n=40) or quetiapine (n=40) for 12 months. Prolactin concentration, weight and height were measured one day before starting treatment and 1, 3, 6, 9 and 12 months after initiating treatment. Severity of symptoms was assessed at the same time periods using the Positive and Negative Syndrome Scale (PANSS).

Results

Thirty-one patients in the risperidone group and 33 patients in the quetiapine group completed the 12 months of treatment. PANSS scores decreased at each follow-up assessment for both groups; the improvement was significantly greater in the risperidone group after 3 months and 6 months of treatment but by the 9th month of treatment the level of improvement in the two groups was similar. In the quetiapine group serum prolactin remained stable throughout the 12 months but in the risperidone group the serum prolactin level increased 3.5- to 5.2-fold over the one-year follow-up. Weight gain was seen in both groups, particularly during the first 3 months of treatment: 62% of the increase in BMI in both groups had occurred by the end of the 3rd month of treatment. No between-group differences in weight changes were observed. The correlation between changes in weight and changes in prolactin levels were weakly positive: r_s=0.17(p=0.104) in the risperidone group and r=0.07 (p=0.862) in the quetiapine group.

Conclusions

Risperidone and quetiapine had similar efficacy in the first year of treatment of first-episode schizophrenia though risperidone was more rapidly effective. Use of risperidone was associated with chronic hyperprolactinemia but this did not occur with quetiapine. Long-term use of both drugs was associated with sustained weight gain; the timing and magnitude of the weight gain is similar for the two drugs. Weight gain was not strongly related to changes in prolactin levels.

Almost all antipsychotics result in weight gain: a meta-analysis

Introduction

Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration of AP use is longer.

Method

A meta-analysis was conducted of clinical trials of AP that reported weight change. Outcome measures were body weight change, change in BMI and clinically relevant weight change (7% weight gain or loss). Duration of AP-use was stratified as follows: ≤6 weeks, 6–16 weeks, 16–38 weeks and >38 weeks. Forest plots stratified by AP as well as by duration of use were generated and results were summarised in figures.

Results

307 articles met inclusion criteria. The majority were AP switch studies. Almost all AP showed a degree of weight gain after prolonged use, except for amisulpride, aripiprazole and ziprasidone, for which prolonged exposure resulted in negligible weight change. The level of weight gain per AP varied from discrete to severe. Contrary to expectations, switch of AP did not result in weight loss for amisulpride, aripiprazole or ziprasidone. In AP-naive patients, weight gain was much more pronounced for all AP.

Conclusion

Given prolonged exposure, virtually all AP are associated with weight gain. The rational of switching AP to achieve weight reduction may be overrated. In AP-naive patients, weight gain is more pronounced.

Course of weight gain and metabolic abnormalities in first treated episode of psychosis: the first year is a critical period for development of cardiovascular risk factors

Data on the long-term metabolic side-effects associated with antipsychotics are scarce. Prospective longitudinal studies in medication-naive patients with a first episode of psychosis are a valuable source of information as they provide an assessment prior to the antipsychotic exposure and minimize the effect of potential confounding factors. The aim of this study was to assess the course of weight gain and the incidence of metabolic abnormalities during the first 3 yr of antipsychotic treatment. Data were collected from a cohort of 170 first-episode psychosis patients. They were randomly assigned to haloperidol (32%); olanzapine (32%) and risperidone (36%). The dose used was flexible. The initial antipsychotic treatment was changed when required, based on clinical response and tolerability. The results showed that the mean weight gain at 3 yr was 12.1 kg (s.d. = 10.7). It appeared to increase rapidly during the first year (85% of the total mean weight gain) and then stabilized gradually over time. Total cholesterol, LDL-cholesterol and triglyceride levels followed a similar trajectory with a significant increase only during the first year. No significant changes were detected in the mean values of glycaemic parameters. Two patients with a family history of diabetes developed diabetes type II. At short-term the factors positively associated with weight gain were lower body mass index, male gender and olanzapine treatment. At long-term, functional status and clinical response were the main predictors. The results of our study indicate that the first year of antipsychotic treatment is a critical period for weight gain and metabolic changes. Identification of weight gain patterns may help to inform studies that aim to prevent or mitigate the metabolic adverse events associated with antipsychotic therapy.

Weight change by baseline BMI from three-year observational data: findings from the Worldwide Schizophrenia Outpatient Health Outcomes Database

The aim was to explore weight and body mass index (BMI) changes by baseline BMI in patients completing three years of monotherapy with various first- and second-generation antipsychotics in a large cohort in a post hoc analysis of three-year observational data. Data were analyzed by antipsychotic and three baseline BMI bands: underweight/normal weight (BMI <25 kg/m²), overweight (25-30 kg/m²) and obese (>30 kg/m²). Baseline BMI was associated with subsequent weight change irrespective of the antipsychotic given. Specifically, a smaller proportion of patients gained ≥7% baseline bodyweight, and a greater proportion of patients lost ≥7% baseline bodyweight with increasing baseline BMI. For olanzapine (the antipsychotic associated with highest mean weight gain in the total drug cohort), the percentage of patients gaining ≥7% baseline weight was 45% (95% CI: 43-48) in the underweight/normal weight BMI cohort and 20% (95% CI: 15-27) in the obese BMI cohort; 7% (95% CI: 6-8) of the underweight/normal cohort and 19% (95% CI: 13-27) of the obese cohort lost ≥7% baseline weight. BMI has an association with the likelihood of weight gain or loss and should be considered in analyses of antipsychotic weight change.

Comparison of metabolic changes in patients with schizophrenia during randomized treatment with intramuscular olanzapine long-acting injection versus oral olanzapine

Metabolic changes were examined in patients with schizophrenia during treatment with either oral olanzapine or olanzapine long-acting injection (LAI). Data were collected from patients who had been stabilized on oral olanzapine (10, 15, or 20 mg/day) for ≥4 weeks and then randomized to either continued olanzapine oral treatment (n = 322) or LAI (n = 599; 150 mg/2 weeks, 405 mg/4 weeks, or 300 mg/2 weeks) for up to 24 weeks. Mean and categorical changes in metabolic parameters were analyzed. Mean changes in weight, glucose, and most lipids were generally not significantly different between treatment groups. Weight changes over time followed similar patterns and were not significantly different at endpoint between the two treatment-formulation groups. Low-density lipoprotein cholesterol decreased significantly less among olanzapine LAI-treated patients. Percentages of patients with potentially clinically significant changes in blood glucose and lipid concentrations were similar for the two treatments. Percentages of patients experiencing adverse events related to weight, diabetes, or dyslipidemia were also not significantly different between treatments. Metabolic changes in patients with schizophrenia appeared generally similar during treatment with oral olanzapine or olanzapine LAI.

Management of antipsychotic-related weight gain

Despite variations across individuals and agents, antipsychotics are associated with clearly documented weight gain and adverse metabolic effects. Although increased appetite/caloric intake and various receptors, hormones and peptides have been implicated, biological mechanisms contributing to the increase in weight and glucose and lipid abnormalities with antipsychotics are largely unknown. This has hampered the creation of antipsychotics that are free of cardiometabolic effects, even in antipsychotic-naive/early-phase patients, as well as the development of strategies that can prevent or drastically diminish the adverse cardiometabolic effects. In general, three strategies can reduce the cardiometabolic risk of antipsychotics: switching to a less orexigenic/metabolically adverse antipsychotic; adjunctive behavioral treatments; and adjunctive pharmacologic interventions. However, each of these strategies has only been shown to be modestly effective. Among different behavioral interventions (N = 14, n = 746), group and individual treatment, dietary counseling and cognitive-behavioral therapy seem to be similarly effective. Among 15 different pharmacologic strategies (N = 35, n = 1629), only metformin, fenfluramine, sibutramine, topiramate and reboxetine were more effective than placebo, with the most evidence being available for metformin, and no head-to-head trials comparing individual pharmacologic interventions. However, even in the most successful trials the risk reduction was modest. Weight was not decreased to a pretreatment level, and despite superiority compared with placebo, weight gain still often occurred, particularly in antipsychotic-naive patients and when interventions were 'preventively' coinitiated with antipsychotics. Future research should focus on combining treatment modalities or agents and on exploring novel mechanism-based interventions.

Contributing factors to weight gain during long-term treatment with second-generation antipsychotics. A systematic appraisal and clinical implications

The increased rates of both overweight and obesity reported in severely mentally-ill patients are prevalently due to the use of second-generation antipsychotics (SGAs). Hence, the main purpose of this article is to analyze systematically potential patient- and drug-related factors which may increase the risk of weight gain during long-term treatment with such medications. Literature information published in English since 1966 and last updated on 17 January 2009 was identified through different databases and using various combinations of search terms. Searches provided 242 articles, whereas 6 additional references were identified manually. Peer-reviewed articles focusing on the risk of weight gain during SGA-chronic treatment (at least 52 weeks, N = 81) were acquired. Data were extracted from the 39 peer-reviewed articles which investigated factors potentially associated with an increased risk of this event. Evidence-based information suggests that a number of factors, either patient- (age, baseline BMI/bodyweight, recent onset of psychotic episodes, need of concomitant psychotropic medications) or drug-specific (relative receptorial affinity, timing of weight changes plateau, daily dose, iatrogenic concomitant changes in biochemical metabolic parameters) may contribute to increase either rates and/or magnitude of this effect during long-term treatments with specific SGAs. All contributors and their relationship with specific drugs should be taken into consideration when designing a long-term therapy with SGAs. Among the best studied agents (clozapine, olanzapine, and risperidone) of this class, the latter seems to be the most susceptible drug to the amplifying effects of both patient- and drug-related factors on the risk of inducing weight changes during chronic treatments.

Schizophrenia and physical health problems

OBJECTIVE

To estimate the prevalence of physical health problems in patients with schizophrenia, and to appraise the impact on mortality rates and quality of life (QoL) in such patients.

METHOD

A selective review of clinical articles relating to physical health such as cardiovascular disease, metabolic syndrome and QoL. In addition, current guidelines and recommendations for the monitoring of physical health in schizophrenia were reviewed.

RESULTS

Cardiovascular events contribute most strongly to the excess mortality observed in schizophrenia. Other factors that contribute significantly include obesity, metabolic aberrations, smoking, alcohol, lack of exercise and poor diet - all of which might be targets for health promoting activities.

CONCLUSION

Physical health problems in patients with schizophrenia are common, and contribute to the excess mortality rate, as well as decreasing QoL. Many adverse physical factors are malleable in such patients, and physical benefit may be gained by following practical guidelines for their monitoring and improvement.

Nicotine use and its correlates in patients with psychosis

OBJECTIVE

To examine nicotine use and its correlates among psychotic patients.

METHOD

Longitudinal naturalistic study of 176 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders, and treated with risperidone at study entry. Levels of nicotine use (smoking, snuffing) were measured along with other relevant ratings and measurements (symptoms, drug treatment, side effects, weight, cognitive functions and outcome) at baseline and once yearly for 5 years.

RESULTS

Nicotine use was twice as common as in the general population. Only few nicotine users had started after onset of psychoses. We could not find any differences among nicotine users and non-users in diagnosis, symptoms, side effects, weight, cognitive functions, personality and outcome, cross-sectionally and longitudinally, ruling against the 'self-medication' hypothesis.

CONCLUSION

A parsimonious interpretation of the findings is that patients suffering from psychosis fail to desist from nicotine rather than experience significant positive effects of the usage.

Body mass index and prevalence of obesity in a French cohort of patients with schizophrenia

OBJECTIVE

To evaluate the distributions of body mass index in a large sample of patients with schizophrenia, and to examine the association between body weight and antipsychotic drugs.

METHOD

The data source was baseline data from a national survey conducted in 2005-2006 in 5756 patients.

RESULTS

The mean age of the patients was 37.1 +/- 11.8 years, and the mean BMI was 25.5 +/- 5.2 kg/m(2). In the final logistic regression model, the prevalence of obesity was significantly higher in female patients, age 40-59 vs. 18-29 years, patients in sheltered employment (vs. no income), out-patients (vs. full-time in-patients) and patients treated with concomitant antidepressant. There was a higher rate of obesity, relative to an absence of antipsychotics at entry, for patients receiving the following individual drugs: clozapine, olanzapine, risperidone and amisulpride.

CONCLUSION

In patients treated with atypical antipsychotics, we found a significantly higher prevalence of obesity than in those not treated with any antipsychotic medication.

Accuracy of body image perception and preferred weight loss strategies in schizophrenia: a controlled pilot study

OBJECTIVE

Obesity in severely mentally ill (SMI) populations is an increasing problem, but there is no controlled data regarding the relationship between SMI and weight perception.

METHOD

Fifty patients with schizophrenia and 50 demographically matched control participants were recruited. Weight, height, and body image accuracy were assessed for all participants, and assessments of mood, psychotic symptom severity and anxiety, and preferred modes of weight loss were assessed for the schizophrenia sample.

RESULTS

Patients with schizophrenia were significantly more likely to be obese than controls (46% vs. 18%, P < 0.005), and most patients expressed an interest in losing weight. Obese participants with schizophrenia underestimated their body size (11.0%) more than controls (4.9%) (P < 0.05).

CONCLUSION

Patients with schizophrenia are more likely to underestimate their body size, independent of the effects of obesity. However, they also express concern about weight issues and willingness to participate in psychoeducational groups targeted at weight loss.

Clinical decision-making during 5 years of antipsychotic treatment

OBJECTIVE

Explore how clinicians select drug treatment based on symptoms, side effects and patient factors, including patient participation in the process, and the association between these factors and attitudes towards drugs.

METHOD

A cohort of 166 patients initially treated with risperidone was followed with yearly assessments over 5 years. At the end of the study, 101 patients were evaluated of whom 58 were still treated with risperidone.

RESULTS

More women than men remained in the study, and on the initial medication. The most common reason for medication switch was lack of efficacy. Clinicians and patients agreed well in their global ratings of medication effects and side effects. Robust associations between switch decisions and patient characteristics including symptoms and side effects could not be identified. The effects of switches were rated as better by the clinicians than by the patients. Negative drug attitudes were associated with pronounced positive symptoms (threshold effect), whereas the corresponding association with 'lack of judgment and insight' was linear over the whole range.

CONCLUSION

The decision-making process appears to have many unknown components, and may benefit from more active patient involvement by using structured clinician and patient rating scales for monitoring the treatment. Such shared decision-making may improve compliance.

Prolactin level during 5 years of risperidone treatment in patients with psychotic disorders

OBJECTIVE

To investigate prolactin levels and related side effects in 128 men and 90 women initially treated with risperidone.

METHOD

Patients initially treated with risperidone were followed over 5 years, during which 45% were switched to other antipsychotic drugs.

RESULTS

Initially, prolactin levels were fivefold the norm in women, and threefold in men. Diagnosis did not affect the prolactin level if adjustment for sex, current age, and age at onset of psychosis was applied. Prolactin levels did not correlate significantly neither with any Positive and Negative Symptom Scale item or subscale, nor with side effects. Drugs other than risperidone were not associated with high prolactin levels. For patients on continuous monotherapy risperidone treatment, there was a marked linear reduction of prolactin level over all 5 years.

CONCLUSION

Risperidone induces a higher prolactin elevation than other atypical antipsychotics, but the effect adapts over time. Prolactin was not associated with expected side effects (e.g. sexual, mental, or weight gain).