What clinical measurements and laboratory tests should be done in adult patients on second-generation antipsychotics to monitor them for possible development of metabolic side effects?
When and how often should these evaluations be done?
A small number clinicians test more frequently than is needed but, unfortunately, the majority do these evaluations less often than is recommended (or not at all; Mitchell et al., 2012; Weisman et al., 2012; Dhamane et al., 2013 ).
Who decides?
As of January 2019, the key guideline on this issue of how to monitor adult patients who are on a second-generation (“atypical”) antipsychotic for metabolic syndrome is still the classic paper published in 2004 from a consensus development conference of several leading professional organizations. See References below. The full text of this article is available free at this link: http://care.diabetesjournals.org/content/27/2/596.full.pdf
But, I will summarize the main points here for you.
What should be monitored and how often?
The consensus conference guidelines recommend monitoring of the following with regard to potential metabolic side effects of second-generation antipsychotics.
Different aspects of the monitoring should be done at Baseline, 4 weeks, 8 weeks, every 3 months, once a year, and every 5 years.
According to the Consensus guideline, all of the following should be done at Baseline. Then, after starting the second-generation antipsychotic:
Personal/family history: Annually
Weight (BMI): At 4 weeks, 8 weeks, 12 weeks, and then quarterly
Waist circumference: Annually
Blood pressure: At 12 weeks and then annually
Fasting plasma glucose: At 12 weeks and then annually
Fasting lipid profile: At 12 weeks and then every 5 years
Notes:
– This is the minimum monitoring they recommended.
– Of course, if a significant change and/or abnormality is found, the frequency of monitoring should be increased.
– Obviously, it does not matter who does the monitoring. For example, it may be the primary care physician who is measuring some or all of these things. But, we cannot rely on the primary care physician because it is very unlikely that they will measure some of these things at the frequencies recommended above. If we are prescribing the second-generation antipsychotic, ultimately we must make sure that this monitoring is being done.
– One important criticism that I have of this guideline is that it recommends the same monitoring for all the second-generation antipsychotics irrespective if they carry a low, medium, or high risk of metabolic side effects. Does it make sense to do metabolic monitoring with equal intensity in patients on lower-risk medications like aripiprazole or ziprasidone and patients on higher risk medications like olanzapine?
– Also, I have bad news–publication of this consensus guideline does not seem to have significantly improved the prevalence of metabolic monitoring in patients on second-generation antipsychotics (Dhamane et al., 2012). So, we’ll have to think harder about how to improve the situation.
– What kind of monitoring do you for possible metabolic side effects in patients on second-generation antipsychotics? Please post your comments under “Leave a Reply” at the bottom of this page.
Comments on measuring weight circumference
Measuring the waist circumference is important and measuring the weight alone is not enough. This is because visceral fat is bad metabolically.
But, measuring waist circumference requires a specific method and is not done by simply putting a tape measure around the patient’s waist.
Some thoughts about weight circumference:
Also, in mental health practice, to be frank, it is awkward to put your arms around the patient’s waist to measure the patient’s waist circumference. I know that we are medical professionals and I am not saying that we should not measure waist circumference. I am just acknowledging something that is a fact.
If the patient is not overweight, is there any need to measure the waist circumference at baseline?
Similarly, if the weight has not shown a significant increase, is there any need to check or recheck waist circumference annually?
Related Pages
How to monitor for metabolic side effects in children and adolescents on a second-generation (atypical) antipsychotic
Monitoring form for second-generation antipsychotics
Metformin to prevent or treat metabolic adverse effects due to antipsychotics
Who is more likely to benefit from metformin for management of metabolic adverse effects?
Potential adverse effects of metformin
Tips on prescribing metformin
Can we use topiramate to treat medication-induced weight gain?
Metformin and topiramate for metabolic adverse effects?
References
American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. J Clin Psychiatry. 2004 Feb;65(2):267-72. PubMed PMID: 15003083.
Dhamane AD, Martin BC, Brixner DI, Hudson TJ, Said Q. Metabolic monitoring of patients prescribed second-generation antipsychotics. J Psychiatr Pract. 2013 Sep;19(5):360-74. PubMed PMID: 24042242.
Mitchell AJ, Delaffon V, Vancampfort D, Correll CU, De Hert M. Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices. Psychol Med. 2012 Jan;42(1):125-47. Review. PubMed PMID: 21846426.
Weissman E, Jackson C, Schooler N, Goetz R, Essock S. Monitoring metabolic side effects when initiating treatment with second-generation antipsychotic medication. Clin Schizophr Relat Psychoses. 2012 Jan;5(4):201-7. PubMed PMID: 22182457.
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mo dattu says
February 25, 2019 at 9:23 pmA major? obstacle is that as psychiatrists we rarely perform physical exams on a regular basis (or it may be me that’s the rare one who doesn’t). You have to have someone roll up their sleeve (maybe take off a sweater first?), take off their shoes, are they wearing a lot of clothes today compared to last time? Labs just seem a lot easier and more accurate. Patients, perhaps females more often, are quite sensitive about weight gain and many weigh themselves on a scale at home. So getting labs, report of weight from the patient and blood pressure from PCP can be enough without weight circumference? I hope so.
Lisa Weldon, PMH-NP says
January 7, 2019 at 2:38 pmFor my patients in residential settings, I like to do a monthly waist circumference, because it helps to notify them if their girth is getting out of control/helps them focus on losing weight and eating more carefully.