Letters to the Editor
Should Lipids be Monitored During the First Year of Treatment with an Atypical Antipsychotic?
Dear Editor:
Recent studies have demonstrated a high prevalence of hyperglycemia and dyslipidemia in patients who are treated with atypical antipsychotics. The highest prevalence of these disorders has been observed with clozapine and olanzapine, but they have also been reported with risperidone and quetiapine (1–4). In a recent article, Meyer proposed quarterly fasting total triglycerides and cholesterol during the first year of atypical antipsychotic therapy, and many colleagues follow this recommendation (4). Recent pharmacoepidemiologic studies, however, suggest that a significant number of patients with schizophrenia discontinue their medication for various reasons within the first year of treatment. Glick and Berg reported the survival analysis of 2 clinical trials with olanzapine and risperidone in schizophrenia (5). In the first study, 37% of patients treated with olanzapine discontinued their medication at 12 months follow-up, owing to adverse events or lack of efficacy. In the second study, survival analysis at 6 months demonstrated that 27% and 32% of all patients treated with olanzapine or risperidone, respectively, discontinued their medication. In a naturalistic study, Binder and others reported that only 36.2% (21/58) schizophrenia and schizoaffective disorder patients were still on risperidone at 2-year follow-up (6). Our own naturalistic study indicates that, among the individuals with schizophrenia or schizoaffective disorder treated with either olanzapine, risperidone, or clozapine at the time of their discharge from the hospital, 36%, 22%, and 8%, respectively, have discontinued their antipsychotic 1 year later (7). The reasons for discontinuing were failure to achieve a therapeutic effect, noncompliance, and adverse side effects. Thus, one has to question the cost-effectiveness of some of the proposed laboratory monitoring with atypical antipsychotics. Diabetic ketoacidosis can occur in the first few months after initiating clozapine and olanzapine, and the prevalence and short-term health consequences justify regular monitoring of glycemia during the first year of treatment. By comparison, the immediate health consequences owing to weight gain and dyslipidemia are not a major concern in the first year of treatment, and monitoring of lipid parameters cannot be justified economically. However, clinicians should make patients aware of the risk of dyslipidemia with atypical antipsychotics, and preventive measures such as diet and physical exercise should be encouraged early in the treatment.
References
1. Osser DN, Najarian DM, Dufresne RL. Olanzapine increases weight and serum triglyceride levels. J Clin Psychiatry 1999;60:767–70.
2. Henderson DC, Cagliero E, Gray C, Nasrallah RA, Hayden D, Schoenfeld DA. Clozapine, diabetes mellitus, weight gain, and lipid abnormalities: A five-year naturalistic study. Am J Psychiatry 2000;157:975–81.
3. Meyer JM. Novel antipsychotics and severe hyperlipidemia. J Clin Psychopharmacol 2001;21:369–74.
4. Meyer JM. A retrospective comparison of weight, lipid, and glucose changes between risperidone and olanzapine-treated inpatients: metabolic outcomes after 1 year. J Clin Psychiatry 2002;63:425–33.
5. Glick ID, Berg PH. Time to study discontinuation, relapse, and compliance with atypical or conventional antipsychotics in schizophrenia and related disorders. Int Clin Psychopharmacol 2002;17:65–8.
6. Binder RL, McNiel DE, Sandberg DA. A naturalistic study of clinical use of risperidone. Psychiatric Services 1998;49:524–6.
7. Landry P, Benaliouad F. Clinical use of atypical antipsychotic in the first year of treatment: a naturalistic study. Forthcoming.
Pierre Landry, MD, PhD, FRCPC
Montreal, Quebec
Faïza Benaliouad, BSc
Montreal, Quebec
|
