"Atypical" Antipsychotic Metabolic Monitoring Remains Poor

Coronary artery disease (CAD) is the leading cause of death in patients with psychiatric disorders. Problems with glucose and lipid metabolism significantly contribute to CAD. However, monitoring and treatment of such problems, as well as other cardiac risk factors, is undertaken rather less often in patients with psychiatric disorders compared with the general population. In 2004, the American Psychiatric Association, in conjunction with other organizations, issued guidelines regarding monitoring of metabolic parameters in patients taking second generation ("atypical") antipsychotics (SGA). They made clear, specific recommendations regarding monitoring weight, BMI, BP, and glucose and lipid data, in addition to other parameters. The FDA also recommended monitoring for metabolic adverse effects of SGAs. Despite much publicity and education about the APA and FDA recommendations, patients are still not being monitored routinely. This is a problem. It is clear that SGA cause glucose and/or lipid perturbations in a significant portion of patients taking such agents.

Intuitively, it might seem that one reason for this is the high portion of patients taking these drugs who are followed in indigent mental health clinics, where the time available for each appointment is short. However, recent data suggest that is not correct. Insured patients are also affected. Haupt et al. looked at metabolic monitoring in patients with insurance before (n=5,787) and after (n=17,832) the guidelines were released. This was a retrospective analysis of a large managed care database, with data sampled from records between 2000 and 2006. Pre-guideline and post-guideline cohorts were identified based on the guideline publication dates. The authors evaluated whether patients were tested at baseline, e.g. initiation, and at around 12 weeks after initiation of SGA pharmacotherapy.

They found that matters improved after the guidelines, but not much: The data are as follows ("pre" = preguideline group; "post" = post-guideline group):

Lipid testing: Baseline: Pre: 8.4%; Post: 10.5%. 12 week: Pre: 6.8%; Post: 9.0%

Glucose: Baseline: Pre: 17.3%; Post: 21.8%. 12 week: Pre: 14.1%; Post: 17.9%

All of the above differences were statistically significant.

It is worth noting that 12 week monitoring rates were less than baseline rates. Follow up appears to be a problem. As well, there were subgroup differences. Children under 12 were much less likely to be monitored, but that group also showed the greatest increase in monitoring rates after the issuance of the guidelines. Oddly, males were significantly less likely to receive glucose testing. The number of primary care provider visits prior to SGA initiation and the presence of preexisting metabolic disorders also affected testing rates.

A detailed discussion of limitations is in the paper. Most probably don't affect the reliability of the conclusions. Also, a caveat: 4 authors were employed by companies involved in the sale and marketing of aripiprazole, an SGA which may cause fewer metabolic adverse effects than some other SGA.

The improvement in monitoring after the APA guidelines were issued was statistically significant, but this is probably largely due to large sample size. "Real world" significance is another matter: It certainly doesn't seem that a 4.5% increase in baseline glucose monitoring constitutes clinical significance. And, a monitoring rate of barely above 10% for lipids and less than a quarter for glucose is quite unacceptable.

SGAs cause glucose and lipid problems in many patients. Monitoring for this is essential, but it is not being done routinely. We must do better.