**6.2 Monitoring**

To monitor for antipsychotic – associated metabolic disturbances, patients should be assessed before antipsychotic treatment is initiated. The results of such an assessment can also influence antipsychotic choice, particularly when patients have existing metabolic pathology or elevated risk factors. The frequency of subsequent assessments is different as it is reflected in the various antipsychotic monitoring guidelines: Mount Sinai (Chobarian et al, 2003), Australia (Lambert et al, 2004) ADA-APA(ADA,2004) Belgium (De Nayer, 2005), United Kingdom (Expert Consensus Meeting, 2004), Canada (Canadian Diabetes Association, 2005), France (Saravane et al, 2009) (Table 6).To summarize these recommendations, there are many aeras of general agreement about the importance of baseline monitoring before starting treatment and that patients should be followed more closely for the first 3 to 4 months of treatment, with subsequent ongoing reevaluation. The utility of the following tests and measures was emphasized: fasting plasma glucose, fasting lipid profile, weight and height, waist circumference, and blood pressure.

A recent study characterizes associations between the combined warnings and recommendations and baseline metabolic testing and Second-Generation Antipsychotic Drugs (SGA). A total of 109451 patients receiving Medicaid who began taking SGA was compared to a control cohort of 203527 patients who began taking albuterol but did nor receive antipsychotic medication. The main outcome measures was the monthly rates of baseline serum glucose and lipid testing for SGA-treated and propensity-matched albuterol-treated patients and monthly share of new prescriptions for each SGA drug. In a Medicaid-receiving patients, baseline glucose and lipid testing for SGA was infrequent and showed little change following the monitoring recommendations. Initial testing rates for SGA-treated patients were low: glucose, 27%; lipids, 10%. The warning was not associated with an increase in glucose testing among SGA-treated patients and was associated with only a marginal increase in lipid testing rates: 1.7%; P=. 02.(Morrato, 2010).

The important question is given the risks in patients with mental illness, how should they be monitored and how should they be treated?

Current studies indicate that patients with mental illness do not receive adequate evaluation and effective treatment of their cardio-metabolic problems. Effective communication between the primary care physician and the psychiatrist is very important for the mentally ill because of their impaired capacity to care for themselves. Such communication will improve monitoring, help early detection of metabolic disorders, and limit duplication of clinical or laboratory workup. Monitoring for metabolic side effects is primarily the responsibility of the physician prescribing antipsychotic medication and in most cases that would be a psychiatrist.

If the primary care physician observes that the patient is being prescribed such drugs without being monitored effectively, he/she should discuss this with the psychiatrist. The psychiatrist may not have the expertise to manage any abnormalities that are detected and in such situations the primary care physician will most likely take over both monitoring and management. Liaison should extend to any healthcare professionals involved in the care of patients with mental illness.

Given the serious health risks, patients taking antipsychotic drugs should receive appropriate baseline screening and ongoing monitoring.

To monitor for antipsychotic – associated metabolic disturbances, patients should be assessed before antipsychotic treatment is initiated. The results of such an assessment can also influence antipsychotic choice, particularly when patients have existing metabolic pathology or elevated risk factors. The frequency of subsequent assessments is different as it is reflected in the various antipsychotic monitoring guidelines: Mount Sinai (Chobarian et al, 2003), Australia (Lambert et al, 2004) ADA-APA(ADA,2004) Belgium (De Nayer, 2005), United Kingdom (Expert Consensus Meeting, 2004), Canada (Canadian Diabetes Association, 2005), France (Saravane et al, 2009) (Table 6).To summarize these recommendations, there are many aeras of general agreement about the importance of baseline monitoring before starting treatment and that patients should be followed more closely for the first 3 to 4 months of treatment, with subsequent ongoing reevaluation. The utility of the following tests and measures was emphasized: fasting plasma glucose, fasting

A recent study characterizes associations between the combined warnings and recommendations and baseline metabolic testing and Second-Generation Antipsychotic Drugs (SGA). A total of 109451 patients receiving Medicaid who began taking SGA was compared to a control cohort of 203527 patients who began taking albuterol but did nor receive antipsychotic medication. The main outcome measures was the monthly rates of baseline serum glucose and lipid testing for SGA-treated and propensity-matched albuterol-treated patients and monthly share of new prescriptions for each SGA drug. In a Medicaid-receiving patients, baseline glucose and lipid testing for SGA was infrequent and showed little change following the monitoring recommendations. Initial testing rates for SGA-treated patients were low: glucose, 27%; lipids, 10%. The warning was not associated with an increase in glucose testing among SGA-treated patients and was associated with only a marginal increase in lipid testing rates: 1.7%; P=. 02.(Morrato,

The important question is given the risks in patients with mental illness, how should they be

Current studies indicate that patients with mental illness do not receive adequate evaluation and effective treatment of their cardio-metabolic problems. Effective communication between the primary care physician and the psychiatrist is very important for the mentally ill because of their impaired capacity to care for themselves. Such communication will improve monitoring, help early detection of metabolic disorders, and limit duplication of clinical or laboratory workup. Monitoring for metabolic side effects is primarily the responsibility of the physician prescribing antipsychotic medication and in most cases that

If the primary care physician observes that the patient is being prescribed such drugs without being monitored effectively, he/she should discuss this with the psychiatrist. The psychiatrist may not have the expertise to manage any abnormalities that are detected and in such situations the primary care physician will most likely take over both monitoring and management. Liaison should extend to any healthcare professionals involved in the care of

Given the serious health risks, patients taking antipsychotic drugs should receive

lipid profile, weight and height, waist circumference, and blood pressure.

**6.2 Monitoring** 

2010).

monitored and how should they be treated?

would be a psychiatrist.

patients with mental illness.

appropriate baseline screening and ongoing monitoring.


Table 6. Recommended guidelines to monitor and initial workup.
