**6. Screening and monitoring**

Identification of treatable pathology in a high-risk population, that is, screening for diabetes, dyslipidemia, hypertension is important and facilitates preventive strategies and early diagnosis. Another goal is to track metabolic disturbance in relation to antipsychotic treatment. Dyslipidemia is a general term that defines an increase in the serum concentration of various lipoproteins. Lipoproteins are usually classified into three major categories:


### **6.1 Screening**

356 Dyslipidemia - From Prevention to Treatment

taking no psychotropic drugs. Patients taking SSRIs had a significantly increased prevalence of obesity, abdominal fat, and hypercholesterolemia. The associations with this factors were significant after adjustment for age, gender , and several covariates. The individuals SSRIs might display differences in their side effect profile, the study performed analysis of the various SSRIs. Paroxetine was strongly associated with general and abdominal obesity but not with hypercholesterolemia, whereas citalopram was associated with neither obesity nor dyslipidemia. Patients taking sertraline, fluoxetine, or fluvoxamine, SSRIs treatment was significantly associated with abdominal obesity and with hypercholesterolemia. SSRIs induce transcriptional activation of cholesterol and fatty acid biosynthesis. The lipogenic effect could represent a common mechanism for explaining in part the lipid disturbances

Weight gain is a major side effect of the main mood stabilizers. Chronic treatment with lithium is associated with increased weight, reaching more than 10kg in 20% of patients (Garland et al, 1998).Valproic acid leads to unequivocal weight gain. Lamotrigene, another anticonvulsant that acts as a mood stabilizer, is not associated with significant weight gain

With regard to mood stabilizers, additional factors could be involved. An insulin-like action cause by lithium at the treatment stage could increase fat deposition. In addition, edema secondary to sodium retention and subclinical hypothyroidism also contribute to weight gain (Garland et al, 1998). The mechanism by which the valproic acid causes weight gain is still little explored; an action in the sense of inhibiting oxidation of fatty acids might be

Studies are not in accordance. A controlled study, with children undergoing anticonvulsant treatment, did not find significant changes in HDL and triglycerides levels associated with use of carbamazepine or valproic acid. But, in the group taking carbamazepine, there were

Another study assessed 101 patients undergoing anticonvulsant therapy for at least 3 months. Compared with controls paired for gender and age, patients taking valproic acid presented significantly lower total cholesterol and LDL levels; patients taking carbamazepine presented significantly increased HDL and apolipoprotein A levels

Identification of treatable pathology in a high-risk population, that is, screening for diabetes, dyslipidemia, hypertension is important and facilitates preventive strategies and early diagnosis. Another goal is to track metabolic disturbance in relation to antipsychotic treatment. Dyslipidemia is a general term that defines an increase in the serum concentration of various



proportional to the serum concentration of high-density lipoproteins (HDLs). - HDL particles are antiatherogenic lipid particles, and high serum levels of HDL are

was significant increase in total cholesterol levels (Fanzoni et al, 1992).

lipoproteins. Lipoproteins are usually classified into three major categories:

protective against coronary artery disease.

directly correlated with the risk of myocardial infarction and death.

(Reader et al, 2006).

(Zimmermann et al, 2003).

involved (Isojärvi et al, 1998).

(Calandre et al, 1991).

**6. Screening and monitoring** 

In the general population, lipid screening with a fasting lipid profile (total chol, LDL, HDL and triglyceride) is recommended for all adults aged 20 years and older, repeteated every 5 years in asymptomatic individuals (Expert Panel on Detection, Evaluation and Treatment, of High Blood Cholesterol in Adults, 2001). Adequate fasting, about 10 to 12 hours is necessary to obtain valid LDL and triglyceride levels-Target LDL levels are determined by a Framingham assessment based on age, sex, chol, HDL, systolic blood pressure, and smoking status (Wilson et al, 1998). Patients on antipsychotic treatment frequently have a metabolic dyslipidemia with elevations of triglyceride and reduced HDL (Cohn et al, 2004), along with associated features of the metabolic syndrome. Some SSRIs induced metabolic disturbance particularly hypercholesterolemia.

Treatment of metabolic dyslipidemia is a secondary goal for intervention following achievement of LDL targets. Clinical trials show that LDL-lowering therapy reduces risk for coronary heart disease (CHD). For these reasons, ATP III continues to identify elevated LDL cholesterol as the primary goal of cholesterol-lowering therapy. Those with diabetes or established cardiovascular disease are considered high risk and are treated to the most stringent LDL targets. Risk determinants in addition to LDL cholesterol include the presence or absence of CHD, other clinical forms of atherosclerotic disease , and the major risk factors other than LDL. Other major risk factors are cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD, diabetes and age. These major risks are commonly observed in patients with mental illness.

A variety of medical conditions and drugs can exacerbate hyperlipidemias. Elevations of the serum LDL cholesterol level can occur in response to hypothyroidism and nephrotic syndrome. Hypertriglyceridemia and decreased HDL levels are commonly seen with insulin resistance, diabetes, and the metabolic syndrome. This fact is usually seen in patients with mental illness. Individuals are characterized by their coronary risk profile according to the National Cholesterol Education Program Adult Treatment Panel III guidelines, as shown in Table 5.


Table 5. ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)

Dyslipidemia and Mental Illness 359

Patients to monitor

Schizophrenia SGA

x x x x x x x

x x x x x x

x x x x x x

x x x x x x

x x x x x

Belgium UK Canada France

Schizophrenia

up

All patients any antipsychotic

Schizophrenia any antipsychotic

APA

All patients SGA

x x

OGTT Follow

x

Lipids x x x x x x Weight x x x x x x Height x x x x x x

Hip x x

x x x

ECG x

The recommendations are that baseline screening measures be obtained before or as soon as clinically feasible after, the initiation of any antipsychotic medication. We have to consider ethnicity, dietary habits, physical activity, support system, smoking, and alcohol and drug

Australia ADA-

All patients any antipsychotic

Ethnicity x x x Tobacco x

Table 6. Recommended guidelines to monitor and initial workup.

Mount

Schizo-

Hba1c If FPG not

feasible

Fasting Plasma Glucose (FPG)

Random glucose

Waist circumference

Family and medical history

Diet activity

Signs and symptoms of diabetes

Blood pressure

**6.2.1 Baseline monitoring** 

Sinaï

phrenia any antipsychotic
