We are pleased to
continue our short series of articles in Partners in Health
UpdateSM that is designed
to explore potential barriers and opportunities to facilitate communication and
collaboration between
primary care physicians and behavioral health providers and to achieve optimal
outcomes for your
patients.
Part 4 ? Second generation antipsychotic
medications
Independence and Magellan Healthcare, Inc. (Magellan) have been encouraging
all primary care physicians and
behavioral health providers to communicate with each other about their
patients. This is one example of a crucial need
to make sure ongoing communication occurs.
Second generation antipsychotic (SGA) medications, also known as atypical
antipsychotic medications, have been
used in psychiatry since 1990 when clozapine (Clozaril®) was
approved for treatment-resistant schizophrenia. Today,
these medications are being prescribed by providers of many specialties, not
just psychiatry.
As more medications for this class of drugs are being developed, we expect
use of these medications to continue. Use
of these medications is prompted by their association with fewer
anticholinergic and movement side effects than the
typical antipsychotic medications such as haloperidol (Haldol®).
These side effects are very uncomfortable for patients.
However, SGAs have presented other side effects, known as Metabolic
Syndrome.1 Metabolic Syndrome includes
hyperglycemia, hyperlipidemia, hypertension, and increase in weight. Current
literature does not show that Metabolic
Syndrome is dose- or time-related,2 so all providers who prescribe
an SGA need to monitor for Metabolic Syndrome.
Monitoring for Metabolic Syndrome
The current SGA medications approved by the U.S. Food and Drug
Administration include:
- aripiprazole (Abilify®)
- asenapine (Saphris®)
- clozapine* (Clozaril®)
- iloperidone (Fanapt®)
- lurasidone (Latuda®)
- olanzapine (Zyprexa®)
- olanzapine/fluoxetine (Symbyax®)
- paliperidone (Invega®)
- quetiapine (Seroquel®)
- risperidone (Risperdol®)
- ziprasidone (Geodon®)
The chart below shows monitoring protocols that are recommended by the
American Diabetes Association and
American Psychiatric Association.3 More frequent assessments may be
warranted based on clinical status.
| Baseline | Week
4 | Week 8 | Week 12 | Quarterly | Annually | Every
5 years |
Medical History | X | | | | | X | |
Weight (BMI) | X | X | X | X | X | | |
Waist Circumference | X | | | | | X | |
Blood Pressure | X | | | X | | X | |
Fasting
Glucose/hemoglobin A1C | X | | | X | | X | |
Fasting lipids | X | | | X | | | X |
All prescribing providers should explain the need for this monitoring as
well as the potential side effects whenthey discuss treatment with their
patients and request their informed consent. Independence and Magellan have
collaborated to provide practitioners with information on atypical
antipsychotic medication management, including
a patient handout to educate your patients on antipsychotic medication
management and potential risks. You can
access this information on our website.
*Alert: Clozapine is also associated
with agranulocytosis and in order to dispense this medication, the pharmacy
must have an Absolute Neutrophil
Count (ANC) on file.4 When a provider prescribes clozapine, not only
do they need to monitor for Metabolic Syndrome as recommended but the
ANC must be drawn weekly for the first 6 months, then every 2 weeks for the
next 6 months. If the patient is taking the medication for one year, the
ANC only needs to be drawn monthly.
1 DeHert, M.,
et al (2012). ?Metabolic and cardiovascular adverse effects associated with
antipsychotic drugs.? Nature Reviews Endocrinology.
Vol 8: 114-126.
2 Liao, T.V. & Phan, S.V. (2014).
?Acute hyperglycemia associated with short term use of atypical antipsychotic
medication.? Drugs. 74:2,
183-194.
3 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.? Diabetes Care, 2004;
27: 596-601.
4 Clozaril REMs Program: A single
shared system for Clozapine. May 20, 2016.
Magellan Healthcare, Inc., an independent company,
manages mental health and substance abuse benefits for most Independence
members.