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Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP—or Child and Adolescent Psychiatry—Smart Take, we will look at a growing concern, specifically the significant barriers that limit adherence to clinical guidelines for metabolic monitoring of second-generation antipsychotics (SGAs). In this article, Aouira and colleagues get the psychiatrists’ perspectives on the barriers to adequate metabolic monitoring in youth treated with SGA. This is a significant matter because the prescription of SGAs has skyrocketed rapidly for more indications. Although these medications can benefit many, there is growing recognition of weight gain and metabolic syndrome complications, which are more common in youth than adults. In fact, youth treated with SGAs are 2–3 times more likely to develop type 2 diabetes.
We also know that early metabolic monitoring is critical for early identification and potential prevention of weight gain and metabolic complications. I do not start these medications without first talking with the child and family, explaining the potential side effects, the need for monitoring as a condition of being on the medication, and how important it is to have a regular exercise regimen. Delays can also have potentially lifelong consequences. So, paradoxically, as prescriptions of SGAs continues to increase, adherence to clinical guidelines for monitoring is inadequate. Best practice guidelines are often not followed. So, it is critical to determine the barriers and how we can overcome them, as not doing so puts children at significant risk for lifelong complications, such as diabetes, which also has significant morbidity.
So, what were the most significant barriers to best practices that put children at risk? A big one is the lack of adequate resources to do the necessary monitoring. For example, our outpatient and inpatient clinics are hospital based or close, which facilitates monitoring. Many non-hospital–based clinics, physicians’ offices, and physicians in private practice may not have access to standard equipment, like blood pressure monitoring, scales to measure weight, or waist measurement tapes. Other barriers that need to be overcome include caregivers’ lack of engagement in their child’s treatment. Remember that patients with the disorders we are treating with SGAs do not uncommonly have parents with psychiatric illnesses, such as depression, which can also present a barrier to engagement in their child’s treatment, follow-through, and motivation to do so. We know, for example, that parents with depression can have concentration impairment, have challenges with focus, be overwhelmed by their own symptoms, and lack energy and motivation.
Sometimes, we do not make it any easier for our patients and caregivers, even for those who are motivated. We know that children and even some adults are not very fond of getting their blood drawn, which is critical for adequate metabolic monitoring. Maybe if there is any silver lining with COVID, we are getting somewhat desensitized to shots and needles. However, this can be a big problem, especially in children who are needle phobic. I know physicians who try not to prescribe these medications to avoid the necessary monitoring. That is a problem when medications used to treat severe conditions, like bipolar disorder, psychosis, schizophrenia, and others, are avoided because of the monitoring. There can also be communication problems in offices, such as disorganization, lack of appropriate reminders or adequate staff for monitoring, and confusion about who is doing the monitoring—nurse, doctor, or other staff.
It does seem that psychiatrists are motivated to do it, although obstacles get in the way of good intentions. Sometimes, problems communicating with the child or adolescents, pediatrician, or primary care physician are an obstacle. It should also be noted that some psychiatrists express concern about losing rapport with their child patient due to the monitoring—primarily blood draws—and this seemed to be particularly the case when there was a severe mental health diagnosis and pathology. We have to do a better job of educating our colleagues, patients and families, and the community about the risks and benefits and emphasize that prescribing these medications—which can be enormously effective and helpful when prescribed and monitored correctly—can be very dangerous when they are not appropriately monitored with lifelong severe and significant complications. The bottom line, though, is that it is just not responsible to prescribe these medications and not monitor them properly regardless of the reason. In the same way, it would not be reasonable to prescribe a chemotherapy regimen for a cancer patient and not monitor this closely because the diagnosis is severe or the person does not enjoy the workups and blood tests. We do it because it is right and best practice. Remember, knowledge heals and can overcome these challenges and barriers.
So, how do we overcome the challenges? More workforce. Clinics need more nurses and staff so psychiatrists can focus on prescribing the treatment and overseeing the monitoring but can delegate to the nurse and office staff tools for adequate monitoring, reminding them when testing is necessary. As I mentioned, education is essential and leads to increased knowledge. This education should include detailed information about potential outcomes of treatment, severe lifelong complications, and how they can be prevented and detected earlier to minimize their sequelae. Training and providing clinic staff with specific guidelines and algorithms for best practice guidelines, how to monitor, and when to monitor can also be very helpful.
Abstract
Cardiometabolic Risk of Second-Generation Antipsychotic Medications During First-Time Use in Children and Adolescents
Christoph U Correll, Peter Manu, Vladimir Olshanskiy, Barbara Napolitano, John M Kane, Anil K Malhotra
Context: Cardiometabolic effects of second-generation antipsychotic medications are concerning but have not been sufficiently studied in pediatric and adolescent patients naive to antipsychotic medication.
Objective: To study the association of second-generation antipsychotic medications with body composition and metabolic parameters in patients without prior antipsychotic medication exposure.
Design, setting, and patients: Nonrandomized Second-Generation Antipsychotic Treatment Indications, Effectiveness and Tolerability in Youth (SATIETY) cohort study, conducted between December 2001 and September 2007 at semi-urban, tertiary care, academic inpatient and outpatient clinics in Queens, New York, with a catchment area of 4.5-million individuals. Of 505 youth aged 4 to 19 years with 1 week or less of antipsychotic medication exposure, 338 were enrolled (66.9%). Of these patients, 272 had at least 1 postbaseline assessment (80.5%), and 205 patients [corrected] completed the study (60.7%). Patients had mood spectrum (n = 130; 47.8%), schizophrenia spectrum (n = 82; 30.1%), and disruptive or aggressive behavior spectrum (n = 60; 22.1%) disorders. Fifteen patients who refused participation or were nonadherent served as a comparison group.
Intervention: Treatment with aripiprazole, olanzapine, quetiapine, or risperidone for 12 weeks.
Main outcome measures: Weight gain and changes in lipid and metabolic parameters.
Results: After a median of 10.8 weeks (interquartile range, 10.5-11.2 weeks) of treatment, weight increased by 8.5 kg (95% confidence interval [CI], 7.4 to 9.7 kg) with olanzapine (n = 45), by 6.1 kg (95% CI, 4.9 to 7.2 kg) with quetiapine (n = 36), by 5.3 kg (95% CI, 4.8 to 5.9 kg) with risperidone (n = 135), and by 4.4 kg (95% CI, 3.7 to 5.2 kg) with aripiprazole (n = 41) compared with the minimal weight change of 0.2 kg (95% CI, -1.0 to 1.4 kg) in the untreated comparison group (n = 15). With olanzapine and quetiapine, respectively, mean levels increased significantly for total cholesterol (15.6 mg/dL [95% CI, 6.9 to 24.3 mg/dL] P < .001 and 9.1 mg/dL [95% CI, 0.4 to 17.7 mg/dL] P = .046), triglycerides (24.3 mg/dL [95% CI, 9.8 to 38.9 mg/dL] P = .002 and 37.0 mg/dL [95% CI, 10.1 to 63.8 mg/dL] P = .01), non-high-density lipoprotein (HDL) cholesterol (16.8 mg/dL [95% CI, 9.3 to 24.3 mg/dL] P < .001 and 9.9 mg/dL [95% CI, 1.4 to 18.4 mg/dL] P = .03), and ratio of triglycerides to HDL cholesterol (0.6 [95% CI, 0.2 to 0.9] P = .002 and (1.2 [95% CI, 0.4 to 2.0] P = .004). With risperidone, triglycerides increased significantly (mean level, 9.7 mg/dL [95% CI, 0.5 to 19.0 mg/dL]; P = .04). Metabolic baseline-to-end-point changes were not significant with aripiprazole or in the untreated comparison group.
Conclusions: First-time second-generation antipsychotic medication use was associated with significant weight gain with each medication. Metabolic changes varied among the 4 antipsychotic medications.
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Reference
Aouira, N., Khan, S., Heussler, H., Haywood, A., Karaksha, A., & Bor, W. (2022). Practitioners’ perspective on metabolic monitoring of second-generation antipsychotics: Existing gaps in knowledge, barriers to monitoring, and strategies. Journal of Child and Adolescent Psychopharmacology, 32(5), 296-303.
