Letters to the Editor
Potential Risk of Diabetes Mellitus With the Use of Atypical Antipsychotic Medication
Dear Editor:
For the past 10 years, several atypical antipsychotics have been used to alleviate the symptoms of psychosis in a diverse patient population suffering from schizophrenia. During this time, clinicians have encountered benefits as well as a host of side effects in this patient population. Weight gain and the development or exacerbation of diabetes mellitus (DM) continue to be serious issues that have forced clinicians to vigilantly follow up their patients’ metabolic profile to prevent serious consequences.
The following case illustrates the need to monitor individual patients, not only for improvement of psychosis but also for DM as an adverse side effect.
Case Report
Mr B, aged 62 years, is an African American who has suffered from schizophrenia for more than 45 years and was hospitalized owing to exacerbated symptoms of psychosis. He had no history of comorbid substance abuse. He had been free of diabetes, and his family history is negative for DM. His body weight was in the normal range for his age and height, and there had been no dietary changes. Hemoglobin A1c was within normal range. He was started on olanzapine, and the dosage titrated to 20 mg within a few days. His psychotic symptoms began to decrease in intensity, although they had not fully resolved after about 14 days. At this time, his blood glucose rose to almost 200 mg and remained high, requiring an oral hypoglycemic agent. Because of his severe psychotic illness, he was started on ziprasidone, a novel antipsychotic used to treat psychosis, in the hope of gradually weaning him off olanzapine. His blood glucose levels are now back to normal. With the combination of ziprasidone titrated to the optimal dosage of 80 mg twice daily and olanzepine 20 mg at bedtime, his psychosis is well controlled, and he can be discharged in the near future. However, the emergence of DM remains a serious issue in this patient. The rest of his laboratory tests remain normal at this stage.
Discussion
The mechanism for antipsychotic- induced DM is not clear in this case. There was no weight gain during his short period of hospitalization. We hope that over time the antipsychotic crossover will continue to effectively treat his psychosis and that his blood glucose will revert to its pretreatment level, so that the oral hypoglycemic agent can be safely discontinued.
Several retrospective data analyses of patients with diabetes taking antipsychotics have yielded an increased risk of either development or exacerbation of this metabolic condition—up to 3 times the risk with olanzapine, 7 times the risk with clozapine, and 2 times the risk with conventional high-potency antipsychotics (1).
Therefore, careful and regular monitoring for diabetes pre- and posttreatment continues to remain a significant part of the psychopharmacotherapy of schizophrenia. The availability of newer antipsychotics such as ziprasidone and aripiprazole may be a step forward in managing this situation.
Reference
1. Gianfrancesco FD, Grogg AL, Mahmoud RA, Wang RH, Nasrallah HA. Differential effects of risperidone, olanzapine, clozapine, and conventional antipsychotics on type 2 diabetes: findings from a large health plan data base. J Clin Psychiatry 2002;63:920–30.
Dr Vijay Dewan, MD, FRCPC
Omaha, Nebraska
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