Discussion Forum for 2/8/2018

I would like to start by disclosing, I have no experience in furnishing SGAs in adolescents or youth since I work with adults only. I have definitely furnished

SGA’s for transitional youth ages 18-late 20’s in emergent or urgent psychiatric care.

In urgent care I have been mindful of the SGAs I choose weighing efficacy with metabolic risk while looking at patient’s medication history as well. Often when I see patients they have already tried several anti-psychotics and may have established adverse reactions or side effects to certain SGAs already. Other barriers may be getting insurance coverage for some of the newer SGAs that have a better metabolic risk profile such as Abilify or Lutuda if patient is drug naïve. Many insurance companies want to know that other more affordable medications were tried and proven ineffective or not tolerated well before trying the more expensive medications.

Since I have furnished meds mostly in urgent care settings I have not had the opportunity to monitor individuals weight, BP, lipids and glucose over time to see if the medication is causing metabolic syndrome risk in the patient. As patients repeatedly present to the urgent care clinic I have worked at I have definitely seen their weight wax and wane secondary to SGAs, substance use and life style issues.

Although the Vandenberghe et al. article may have some confounders such as not measuring the patients height with weight over time or factoring in weight gain from additional meds the patient may have been on at the same time of the SGAs, it does make me more cognizant of weight gain potential as early as the first 30 days of treatment.

I believe that detecting and treating psychosis during adolescents and youth is a very key moment that shadows that individual’s trajectory of their illness. It is an extremely vulnerable time. The individual is developing autonomy from parents and are hit with a life changing illness. It is very difficult to get this age group to buy into the importance of treatment. Self-image is important, physical health is important and many of these meds have the side effect of lethargy, mental cloudiness and weight gain. Because of this patients often feel as if the meds are making them sicker instead of controlling an illness that these patients and their families may very well be on the fence of whether there is a mental illness or not. All these factors make it really important to monitor patient’s symptoms, side effects objective and subjective more closely at this age and make changes appropriately in concert with patient and family so that the illness is carefully controlled. This includes factoring in how the patient and family regard the side effects of the meds. If issues are arising that demonstrate metabolic syndrome risk this needs to be discussed carefully weighing the pros and cons of stopping and or changing the medication. I appreciate the Dayabandara et al. article that encourages interventions for metabolic risks instead of ceasing medications that exhibit this risk but demonstrate good control of patient psychotic symptoms. Making patients and family feel that the decisions around risk factors are being made with there input helps these patients continue to stay in treatment and seek treatment in the future. With out including them in these decisions there is potential of alienating them from treatment, which increases the risk of the patient fumbling many times on and off meds. This could repeat many times until the illness has become so debilitating that the patient has lost many of their resources such as housing, care givers and/or developed comorbid illnesses such as substance abuse.

The Vandenberghe et al. and article is hopefully the 1^st of many that will study possible ways for treating adolescents with SGAs to develop guidelines for reducing metabolic syndrome risks.

I have attached a meta-analysis study on metabolic syndrome risks with treatment of schizophrenia with anti-psychotics in the adult population. It has helpful guidelines regarding types of antipsychotics and lifestyle issues that factor into these risks, which mirrors the wonderful Dayabandara et al. article Mr Gomez also posted for follow up on our discussion.

Thanks for a great discussion on this important issue.

References

Cooper, S. J. & Reynolds, G. P.,  (2016). BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. Journal of Psychopharmacology. Pg. 1-32. DOI: 10.1177/0269881116645254

Dayabandara, M., Hanwella, R. Ratnatunga, S., Seneviratne, S. Suraweera, C. & A de Silva, V. (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatric Disease and Treatment. 2017:13: 2231-2241.

Vandenberghe, F., Najar-Giroud, A., Holzer, L. Conus, P., Eap C. B., & Ambresin, A. E., (2017). Second-Generation Antipsychotics in Adolescent Psychiatric Patients: metabolic Effects and Impact of a Early Weight Change to Predict Longer Term Weight Gain. Journal of Child and Adolescent Psychopharmacology. 20: 1-8. DOI: 10.1089/cap.2017.0038

Hello everyone, I really enjoyed the presentation by Seth and the points of interest that were brought to light. Like many of my peers, I have little to no experience prescribing SCA’s to youth. This is not my area of practice; however, the article was quite moving and the discussion that followed was even more interesting.  Seth encouraged us to google the authors name to see if this subject was really their area of passion. I never thought of doing that before or after reading an article written by an author. There were several points brought to my attention during the presentation that caused me to stop and take note. Some were common knowledge and some really surprised me. My top five were :1) SGA’s cause the most weight gain especially in youth. 2)At which point should the caregiver start to intervene once the medication has begun and the youth is noticeable gaining a significant amount of weight.3) This article, though it is the first of its type to include youth, should serve as an agent to develop guidelines in the administration of SGA’s and the perpetual weight gain acquired by youth. 4)  Care givers should be educated about weight gain among youth receiving SGA’s. and 5) Weight gain in the youth appears more dramatic than weight gain in an adult due to the development and transition that their bodies are experiencing. Many other ideas were brought to light as well, for instance, the article did not mention other medications that could also contribute to some of the weight gain acquired by the youth. Retrospective studies are less labor intensive because material used in them is already gathered.

I really enjoyed the contribution expressed by my peers in the discussion. It was amazing that everyone was familiar with most of the SGA’s except one (amisulpride). The reason was it is not available in the US market yet. The general consensus of the group was that more research needed to be done before the medical community could take a firm stand on the final conclusion reached by the authors. I really enjoyed the discussion and look forward to our next gathering.  

Although I hope to work with youth as a nurse practitioner, I have limited experience prescribing SGAs to youth/adolescents at this point in my training, and even less experience monitoring/preventing weight gain. At my clinical site most of the children that we see are being treated for anxiety, depression or ADHD, so SGA's are rarely used. We worry most about weight loss/failure to gain weight for clients who are taking stimulants, and rarely have to focus on preventing weight gain for  individuals on antipsychotics. That said, my preceptor and I have started a few adolescents on Risperdal, Seroquel and Abilify for psychosis or in one case for mania. 

Despite the fact that the population in this study is not very reflective of the children/adolescents I see (for reasons discussed in the Journal Club session), this article has served as a good reminder to me about the importance of monitoring weight gain in youth on SGAs. Because we don't see many youth taking these medications at my clinical site, I do not have much experience seeing individual clients gain large amounts of weight. This may be due to the fact that I am new at functioning as a provider, but I suspect it may be more due to a lack of awareness and a tendency to minimize small amounts of weight gain. This article serves as a good reminder, though, of the importance of monitoring weight in youth taking these medications because of the associated risk with later obesity and metabolic syndrome. 

Something I found to be particularly interesting is the idea that even a very small amount of weight gain can be predictive of later problems. This drives home the importance for me of closely monitoring weight, talking about the risks of weight gain with kids/parents and employing tactics to prevent weight gain before it happens. 

In the article and class discussion, we discussed how SGAs are often more problematic in younger patients because they are more sensitive and susceptible to weight gain due to changes in puberty and hormonal changes. Additionally, teens may not have yet established healthy habits that are necessary for weight loss/weight maintenance such as regular exercise and eating a balanced, healthy diet. After reading the article and discussing it amongst the group, the take away is that substantial and rapid weight gain in the first month of a SGA in an adolescent might be predictive of continual weight gain in the future. I also think that this article might be useful in providing evidence to insurance companies or the court in the context of JV-220s to get approval for more weight-neutral SGAs before trialing several other SGAs that have higher risk for metabolic syndrome. For example, one teen in the group home gained almost 20 lbs over the first few months on quetiapine. It might be useful to print out a copy of this article, and present the evidence that he gained far above the recommended 4% in the first month, and therefore, a more expensive weight-neutral SGA is indicated over trialing a different, more inexpensive SGA such as olanzapine. In future practice, it will helpful to have the 4% parameter as a general rule of thumb to keep in the back of my mind, and to meticulously monitor labs and and intervene early when adolescents have substantial weight gain in the first 1-3 months on an SGA. 

I must say that I have limited experience prescribing to adolescents and even less with children in general.  My primary group of focus is the adult and geriatric population.  It seems to be that there are some similarities in these two populations.  As discussed in our journal club this week, second generation antipsychotics (SGAs) are known to cause adverse effects, especially weight gain among other metabolic side effects.  When working with the geriatric population is it imperative to start slow and go slow.  Not only because this is good practice, but because there are usually many comorbid conditions that can be exacerbated by SGAs.  Within the adolescent population it is also important to start low and go slow as their bodies are in a crucial developmental period with hormonal changes that can be effected by introducing SGAs at this phase in life in addition to the known side effects.

As discussed in journal club, I believe that the article just reinforces my monitoring and education practices for all of my clients.  It is important to not only be mindful of SGAs adverse reactions and the side effect profiles, but to be continuously monitoring for these effects in all of our clients.  The article that we discussed did trigger some questions regarding the long-term effects of SGAs.  The article correlated that a >4% weight gain was the likely hood of continued weight gain and complications at later dates (Vandenberghe, et al., 2017).  While the data points in question have some holes in them, I do see there is a correlation. Other research has been conducted regarding psychotropic medications and like the Vandergerghe study, they were able to see a correlation with a short-term weight gain with psychotropic medications (Reekie, et al., 2015).  But more research is needed to understand the long-term effects of these medications.  I would like to know more about these long-term effects and another concern would be how this message is posed to such a vulnerable population that generally have such a focused view on their own body images without being told they will likely gain weight from these medications.  

References:

Reekie, J., Hosking, S. P., Prakash, C., Kao, K. T., Juonala, M., & Sabin, M. A. (2015, May 28). The effect of antidepressants and antipsychotics on weight gain in children and adolescents. Obesity Reviews, 16(7), 566-580.

Vandenberghe, F., Najar-Giroud, A., Holzer, L., Conus, P., Eap, C. B., & Ambresin, A.-E. (2017). Second-Generation Antipsychotics in Adolescent Psychiatric Patients: Metabolic Effects and Impact of an Early Weight Change to Predict Longer Term Weight Gain. JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY, XX(XX), 1–8.

I have no experience with adolescents or youth that are using or have been prescribed Second-generation antipsychotics (SGAs), however, I just cannot imagine the challenges a child, so young already prescribed medications that not only have some serious side effects, but also affects them in multiple aspects of their lives has to endure. They must deal with stigma, accept this mental health diagnosis at such a young age (which will stay with them for the rest of their lives), and trying to function as a regular kid in the community. Therefore, if we are going to prescribe SGAs to adolescents or youth, we must make sure that we provide them with all the resources and tools to help them work through this diagnosis as simply and easy as we can. And that involves educating, providing of resources, and incorporating other treatment regimens.

I don’t work with adolescents or youth, however, if I were to prescribe or inherit a patient who is taking a SGA, I would make sure to educate them from the beginning, therefore, giving them the knowledge to look out for any side effects that could be developing. I would make sure to have my baseline labs and physical, weights, etc. so that I can compare down the road if there seems to be any new or drastic changes. This article did not really impact how I would monitor, but instead, reminded me that there are parameters to help us monitor, but some parameters are not ideal, therefore, we must trust our own assessments, intuition, and patient’s reports and to tailor each treatment regimen to the individual patient.

If I were a regular person with no knowledge of the benefits of treatment for mental illness, I’d be skeptical with SGAs in adolescents and youth. I would prefer that they try different modalities first, but with my knowledge of mental illness, psychosis, and medications, I know it is more harmful to not treat psychosis and schizophrenia, and even more difficult to treat if there is a relapse in psychosis (Emsley et. Al., 2013). So, I don’t have any new questions but hopes to make these medications better with less side effects.

Emsley, R., Oosthuizen, P., Koen, L., Niehaus, D., & Martinez, L. (2013). Comparison of Treatment Response in Second-Episode Versus First-Episode Schizophrenia. Journal of Clinical Psychopharmacology, 33(1), 80-83. doi:10.1097/jcp.0b013e31827bfcc1

Thanks for a journal club that offered some questions to ponder and reflect upon. Something that I started thinking about as a result from this journal club was in regards to when to implement things in practice that I read about in a journal article. This study, like many others out there, are small studies that yield statistically significant results, but may not yield clinically significant results. I am constantly struggling with this, whenever I read articles that are initial studies or studies that are small sample sizes. For example, this article suggested that perhaps we should intervene with SGA treatment if the patient gains 4% of their weight within the first month. While this is excellent food for thought, at what point does this become part of my practice? In this situation, it probably won't cause too many problems, because it is something that needs to be assessed with each individual case. But when it becomes part of our regular practice, but it's not yet considered "standard of practice" or the study is not yet a "landmark study", other practitioners may be quite confused with what you are doing.

One example I can think of is the intervention to start metformin prophylactically when starting a SGA to prevent weight gain/the progression to diabetes. There are studies out there that show that starting metformin (early) when starting an atypical can be beneficial (Hasnian, Vieweg, & Fredrickson, 2010; Jesus, Jesus, & Agius, 2015) to preventing metabolic syndrome and weight gain. While in theory this could make a lot of sense, in practice, this could cause a lot of problems. With the division of care, usually primary care manages diabetes and mental health specialists manage the mood disorder/psychotic disorder, or whatever the SGA is treating. If as specialists we start doing this as our standard of practice, it may be confusing to PCPs who would not typically start Metformin until they receive a diagnosis of diabetes. And if we somehow prevent diabetes, are we depriving the patients of certain care/resources they would have access to if they were "officially" diagnosed with diabetes and then started on Metformin later? And then there is the question of who follows and manages the Metformin when that is not in the PMHNP scope.

I don't have answers to the Metformin/SGA example above, but it makes me think about the transition between when research comes out that gives us promising information that could help our patients and when it becomes standard practice. Before things become standard practice, other practitioners may question our decisions and others may be confused about our decisions. I know we are weighing our decisions each time and taking the individual into consideration; of course we would not automatically switch the SGA if a youth gains 4% of their weight within the month if they are psychiatrically stable for the first time. But with the metformin example above, sometimes our decisions have a much wider impact than just switching an SGA.

Resources:

Jesus, C., Jesus, I., & Agius, M. (2015). A review of the evidence for the use of metformin in the treatment of metabolic syndrome caused by antipsychotics. Psychiatria Danubina, 27(1): 489-491.

Hasnain, M, Vieweg, W. V., Fredrickson, S. K. (2010). Metformin for atypical antipsychotic-induced weight gain and glucose metabolism dysregulation: review of the literature and clinical suggestions. CNS Drugs, 24(3): 193-206. doi: 10.2165.11530130-000000000-00000.

Madhubhashinee, D., Hanwella, R., Ratnatunga, S., Seneviratne, S., Suraweera, C., & de Silva, V. A., (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatric Disease and Treatment, 13, 2231-2241.

Vandenberghe, F., Najar-Giroud, A., Holzer, L., Conus, P., Eap, C. B., & Ambresin, A. Second-Generation antipsychotics in adolescent psychiatric patients: Metabolic effects and impact of an early weight change to predict longer term weight gain. Journal of Child and Adolescent Psychopharmacology, 2017, 1-8. doi: 10.1089/cap.2017.0038.

Reflect on your experience or knowledge regarding use of SGAs in adolescents or youth.  

I don't have extensive experience prescribing SGAs to adolescents, however, I have experience working with adults who have been prescribed them for many years, some since adolescence.  From my experience working with adults I know the side effects can significantly, negatively impact health.  Unfortunately, I haven't seen great interventions for these negative effects.  Of course minimizing medication, monitoring and lifestyle changes are all essential, but my patients often have limited capacity to engage in these lifestyle modifications.  Monitoring at the clinic I'm at varies with more functionally impaired individuals monitored less  frequently than the recommended monthly frequency (Pringsheim, Panagiotopoulos, Davidson, & CAMESA, 2011; Cooper & Reynolds, 2016).  This is, of course, problematic because more impaired individuals likely have a more difficult time engaging in the behavioral/lifestyle interventions that can help mitigate negative metabolic effects.  This further affects their quality of life and longevity.  There is an especially urgent need to mitigate these adverse effects in children and adolescents because, presumably, they have a greater number of years over which to incur the negative and adverse health effects of the side effects of SGAs.   

How does this article impact how you monitor adolescents or youth?  

The article and information I've learned about the metabolic effects of SGAs has reinforced the importance of close monitoring of metabolic parameters in children and carefully considering the metabolic profile of different SGAs.  I was also not aware that prescribing metformin was an effective and advisable intervention when lifestyle modifications are insufficient and switching medications is perhaps ill-advised.

Does this article trigger any new questions you have about SGAs in youth?

I've generally been hesitant to prescribe SGAs to children and psychotropics in general as all medications have costs associated with them. Certainly, there are situations when the costs of an illness outweigh the costs of medication and medication is effective and needed, but I think always carefully considering the metabolic impact of SGAs (and side effects generally of all medications), having a low tolerance for adverse side effects and taking measures to promote lifestyle changes that can mitigate the adverse metabolic effects are essential for providing the best care.  As reported by Vandenberghe, Najar-Giroud, Holzer, Conus, Eap & Ambresin, (2017), initial weight gain appears to be related to overall and future weight gain, so paying specific attention to initial weight gain and modifying treatment (switching medications) in response to initially greater weight gain may help mitigate these effects.  Based on the the readings, I would also initially prescribe SGAs with lower incidence of metabolic syndrome unless there was a clear and strong indication against it (Madhubhashinee, Hanwella, Ratnatunga, Seneviratne, Suraweera, & de Silva, 2017).  Finally, I think it's easy to keep patients on medications without trialing decreased doses or working to minimize polypharmacy, but this is clearly important and something important to be consistently cognizant and reminded of.

Cooper, S. J. & Reynolds, G. P. (2016). BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. Journal of Psychopharmacology, 30(8): 717-748. doi: 10.1177/0269881116645254

Madhubhashinee, D., Hanwella, R., Ratnatunga, S., Seneviratne, S., Suraweera, C., & de Silva, V. A. (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatric Disease and Treatment, 13, 2231-2241.

Pringsheim, T., Panagiotopoulos, C., Davidson, J., Ho, J., & CAMESA guideline group. (2011). Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 20(3), 218.

Vandenberghe, F., Najar-Giroud, A., Holzer, L. Conus, P., Eap C. B., & Ambresin, A. E., (2017). Second-Generation Antipsychotics in Adolescent Psychiatric Patients: metabolic Effects and Impact of a Early Weight Change to Predict Longer Term Weight Gain. Journal of Child and Adolescent Psychopharmacology. 20: 1-8. DOI: 10.1089/cap.2017.0038

While I’ve never prescribed SGAs to youth (I just started working with children in my internship), I have a lot of nursing experience with the use of SGAs in children. I spent several years working in a pediatric psychiatric hospital that included a 36-bed acute hospital and three residential treatment facilities (around 150 beds total) that specialized in sexual maladaptive behaviors, mental retardation/dual diagnosis (MRDD), and conduct disorders. As the nurse, I was responsible for doing the growth chart assessment on initiation and at regular intervals, tracking labs, monitoring and reporting side effects of medications, and providing patient and family education and obtaining consent from legal guardians. Because of the acuity of our clientele, we used a wide range of antipsychotics - the most common maintenance antipsychotics were probably risperidone and quetiapine (though we had a number of treatment-resistant patients on first-gen drugs like chlorpromazine), with olanzapine (oral or IM) the most common acute SGA. Weight gain was a frequent concern, but I recall the patients being much more distressed by other side effects like gynecomastia (especially with risperidone). Anecdotally, the MRDD clients were much more prone to developing type II diabetes and metabolic disorders - I’m not sure if this is due to genetic risk factors, higher likelihood of early initiation of antipsychotic therapy, higher doses needed to obtain desired outcomes, or a combination. My experience is limited by the institutional setting - all meals and snacks were controlled by a well-trained dietary team, so patients who may have had increased appetite with SGAs didn’t necessarily have access to all of the food they might have like to have eaten. In other hospitals I’ve worked in, providers would frequently order “double portions” to improve patient satisfaction and decrease conflict regardless of a client’s actual dietary needs, and weight gain was much, much more common.

This article gave me a chance to reflect on my prior experience, and to see the value of having a strong institutional culture of careful monitoring when prescribing any psychotropic. Providers should implement routing monitoring for relevant conditions, and carefully review the results at every visit. We also need to emphasize patient education, and recognize the patient as a partner in their health - they should be encouraged to help in risk-benefit analysis when it comes to choosing the right medication. This article demonstrates that the development of metabolic problems with SGAs follows a relatively predictable trajectory, so we don’t have an excuse for ‘watchful waiting’ as our young clients develop insulin resistance or other problems.

I think it’s important to remember that SGAs are not unique in their propensity for causing metabolic disorders, and many medications have potential for significant short- and long-term side effects (i.e. movement disorders) that can negatively effect our clients’ quality (and quantity) of life. It’s much easier to intervene in the early stages of weight gain, lab abnormalities, or movement disorders than it is to reverse those effects down the road. 

Good article and good journal club discussion!

The use of second-generation antipsychotics is well known in the field of psychiatry to cause weight gain. Specifically, the prevalence of cardiovascular diseases and conditions can be caused by a variety of factors, but those on antipsychotics have a large increase in weight gain due to the metabolic factors that antipsychotics have on the human body. From my experiences in working with adolescents, many of my patients have some sort of experience with SGA's. However, most of the presenting problems stem from behavioral issues in the home and/or school setting. For that reason, there is a good portion of children in my clinical practice who have yet to be prescribed an SGA. Like the article that was posted, the risks associated with hormonal-based weight gain in addition to an antipsychotic can be quite harmful to his or her health over a longer period of time.

Looking at some other research pertaining to this topic, some researchers believe that SGA's can be highly effective for acute psychiatric disorders for adolescents. However, even with such efficacy carries a risk like the posted article mentioned. Weight gain, sedation, EPS, elevated prolactin levels, and an increased risk of developing diabetes is much more pronounced within this specific age group (Kumra et al., 2007). It was suggested while clinical efficacy is important for stabilization, providers need to provide adequate education and the creation of a treatment plan to address these issues from the early onset of treatment as most of these conditions can gradually become chronic if left untreated.

Kumra, S., Oberstar, J. V., Sikich, L., Findling, R. L., McClellan, J. M., Vinogradov, S., & Charles Schulz, S. (2007). Efficacy and Tolerability of Second-Generation Antipsychotics in Children and Adolescents With Schizophrenia. Schizophrenia Bulletin, 34(1), 60-71. doi:10.1093/schbul/sbm109

I have limited experience in prescribing SGAs to adolescents or children. It was helpful to learn about the effects of SGAs on adolescents from this week’s journal club. Even in an adult, the metabolic side effects of SGAs are an important clinical factor to consider when prescribing and monitoring patients taking SGAs. Since adolescents or youth are going through puberty and hormonal changes, it is logical that the SGA weight gain side effect is much greater in adolescents relative to adults. I would imagine the long-term impacts of SGA therapy are more detrimental for this population both physiologically and psychologically (e.g., bullying, poor self-image). The article reminds me of the importance of patient education and close weight gain monitoring for adolescent or youth taking SGAs. The article triggers a new question about SGAs in youth: is prescribing metformin as an adjunct to SGAs a plausible way to prevent significant weight gain and the metabolic side effects from SGAs? I thought about metformin as a concomitant medication for adolescents on SGAs because it has a weight loss side effect, is a first-line of treatment for diabetes, is relatively safe to use, and potentially prevents the development of diabetes.

I reviewed a few research articles that I found via an online UCSF library and PMC search. I included three articles in this posting. Their conclusions about metformin therapy were not homogenous; however, two of the three I reviewed found a significant metformin benefit in preventing metabolic syndrome related to SGAs.

According to Webb & Viner (2006), metformin has shown small improvements in weight reduction for obese non‐diabetic adolescents with hyperinsulinemia. (Grade B); however, the efficacy and safety of long-term metformin use in children remains unknown. (Grade D).

In a meta-analysis of 12 published studies with a total of 743 patients who were on antipsychotics for schizophrenia or schizoaffective disorder, metformin was significantly effective in treating antipsychotic induced weight gain (Silva, Suraweera, Ratnatunga, Dayabandara, Wanniarachchi, & Hanwella, 2016).

According to Klein, Cottingham, Sorter, Barton, & Morrison (2006), a 16 week double-blind placebo-controlled trial study with 39 children and adolescents aged 10-17 years-old on atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine) concluded that metformin therapy was safe and effective in treating antipsychotic induced weight gain, improved insulin sensitivity, and decreased abnormal glucose metabolism.

Thank you for the great discussion and an opportunity to dissect the article in depth as a group.

References

Webb, E., & Viner, R. (2006). Should metformin be prescribed to overweight adolescents in whom dietary/behavioural modifications have not helped? Archives of Disease in Childhood, 91(9), 793–794. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1136/adc.2006.098962

De Silva, V. A., Suraweera, C., Ratnatunga, S. S., Dayabandara, M., Wanniarachchi, N., & Hanwella, R. (2016). Metformin in prevention and treatment of antipsychotic induced weight gain: a systematic review and meta-analysis. BMC Psychiatry, 16, 341. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1186/s12888-016-1049-5

Klein, D., Cottingham, E., Sorter, M., Barton, B., Morrison, J. (2006). A randomized, double-blind, placebo-controlled trial of metformin treatment of weight gain associated with initiation of atypical antipsychotic therapy in children and adolescents. The American Journal of Psychiatry, 163(12), 2072-2079.

Thank you for posting a video, so that way the remote students are able to access the discussion in class and read the articles. I have to say that the articles we have been reading in this club have been very informative, and the information is useful for us in practice. 

Reflect on your experience or knowledge regarding use of SGAs in adolescents or youth.  

My only experience with adolescents or youth have been with Depression with Suicidal ideations in the emergency room. I rarely encounter encounter psychotic or adolescents with Schizophrenia in the emergency room, who are taking SGAs. I am familiar with the fact that most SGAs has the potential side effects of weight gain (mostly because I work with the adult population where there is significant weight gain), however, in adolescents I was shocked to see that SGAs can cause adolescents to have increase in weight gain that is 4% more than an adolescent who is not taking SGAs. The article this week, was very interesting to read, especially since the majority of SGAs used or recommended for adolescents are risperidone, zyprexa, and seroquel. 

How does this article impact how you monitor adolescents or youth?  

After reading the article, I did some more research and found some other articles that were interesting and informative as well. The impact of monitoring adolescents and youth on SGAs has brought a different perspective in how we will treat. I think a thorough past family medical history is need to be conducted, because we can then know how much the adolescent is at risk for metabolic changes. Also, a baseline lab work up will be necessary, as well as noting the dietary intake at home. One of the limitations in the article suggested that there wasn't information regarding the adolescent's dietary intake and exercise regime. Knowing this information will be helpful in treating adolescents, as well as educating their parents/caregivers. 

The other important information we should consider is collaboration with the pediatric PCP of the adolescent. There was narrative review that discusses the most latest findings in regards to adolescents or youth taking SGAs (Pisano, et al., 2016). The article emphasized the importance of collaboration with the pediatric PCP, and active monitoring. Another important thing to remember is that not only weight gain and metabolic changes with SGAs, but there are also other SGAs, such as Geodon and others that can cause QTc interval prolongation (Pisano, et al., 2016). Therefore, we have to also consider cardiac concerns on top of metabolic changes, and be very thorough in monitoring adolescent patients who are taking SGAs. 

Does this article trigger any new questions you have about SGAs in youth

References:

Pisano, S., Catone, G., Veltri, S., Lanzara, V., Pozzi, M., Clementi, E., … Masi, G. (2016). Update on the safety of second generation antipsychotics in youths: a call for collaboration among paediatricians and child psychiatrists. Italian Journal of Pediatrics, 42, 51. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1186/s13052-016-0259-2

I have no experience and a very limited knowledge regarding the use of SGAs in adolescents. 

This article does impact how I would monitor my patients’ weight and the other side effects associated with SGAs.  Like Yunji I was very curious about the metabolic changes associated with the SGAs.  I knew SGAs affected weight but I didn’t realize that the metabolic changes could be so severe.  However I did read an article that speculated that schizophrenia, and other brain disorders such as Alzheimer’s may be more closely linked to diabetes mellitus than previously believed.  I could not find the exact article I read but searching for it I found some good research articles. 

According to Bailey, Sharpe, Ringel, & Zeeshan (2018), collaborating with the patients’ primary care provider and mental health provider to monitor the patients’ blood sugar and metabolic syndrome, prevent serious complications, and adverse reactions.  Providing a significant amount of education to the patient and their family is necessary, and appropriate.  Drug naïve patients were associated with glucose dysregulation (Wani et al. 2015).  Early detection of metabolic dysregulation is of the upmost importance when monitoring young patients prescribed SGAs. 

The article did make me ponder some questions.  Were the participants screened for genetic predisposition of diabetes or other metabolic disorders?  Were the activity levels of the participants evaluated before the study to determine normal lifestyle habits, such as a sedentary lifestyle? 

References

Bailey, R. K., Sharpe, D. K., Ringel, M., & Zeeshan, A. (2018). Early combination therapy for type 2 diabetes mellitus and common comorbid mental disorders. Foc, 16(1), 48-53. 10.1176/appi.focus.20160048 Retrieved from https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1176/appi.focus.20160048

Wani, R. A., Dar, M. A., Margoob, M. A., Rather, Y. H., Haq, I., & Shah, M. S. (2015). Diabetes mellitus and impaired glucose tolerance in patients with schizophrenia, before and after antipsychotic treatment. Journal of Neurosciences in Rural Practice, 6(1), 17-22. 10.4103/0976-3147.143182 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244781/

SGA use carries the risk of weight gain.  With the increase in weight gain, runs additional risk of developing type 2 diabetes and cardiac complications.  Use of SGA's in adolescents further increases their risk due to undergoing puberty.  The addition of hormones to promote growth in conjunction with side effects from SGA can increase the risk of the adolescent developing secondary health complications as an adult.  Adolescents also have less control of their dietary intake due to reliance on adults and schools for their meals.  If the parents are not feeding the adolescent nutritiously balanced meals, it would be difficult to attribute weight gain to use of SGA's.  

I feel that if a SGA is able to successfully reduce psychiatric symptoms, it would be appropriate to continue its' use.  The healthcare provider should continue to monitor weight with every visit and perform routine labs.  

Below is a good chart to list psychotropic medications with cause weight gain.

Although, I have never prescribed SGAs before, I have administered SGAs countless number of times to both youth and adults. I have had extensive experience as a RN working with both youth and adults in a variety of psychiatric settings such as, juvenile hall, jail/prison, group homes, inpatient psychiatric units, and county psychiatric health facility (PHF), also known as the county “Puff”.  The reason I mention this work experience is that I have first hand, seen the effects of SGA’s on both populations.

Through my own personal assessment over the years, increased weight, diabetes, and high blood pressure were notable in a short period of time in the adolescent population in comparison to the adult population. Although, there are many risk factors that exacerbate metabolic syndrome (Mets) quicker in some than others such as, genetics, family history, and lifestyle (Vandenberghe et al., 2017). My personal hypothesis was that since the adolescent body is changing rapidly, that their bodies are more sensitive to SGA’s than an adult. It appears that Vandenberghe et al. (2017) mentions this is a reason Mets is seen quicker in the pediatric population as well (Vandenberghe et al., 2017).

It was very disheartening seeing pediatric patients struggle with severe mental illness and their quality of life suffering. As we were treating their mental illness, I felt terrible knowing we are exposing them to detrimental health problems that can exacerbate their mental health condition in the long run.

For example, weight gain for an adolescent, especially adolescent female is particularly sensitive since they are constantly bombarded with images of unrealistic females via social media, tv, and magazines, and the pressure to meet those standards. Also, the adolescent period is a time of trying to figure oneself out and “fit” in with peers and becoming interested in pursuing relationships. Many times, low self-esteem contributes to feelings of depression and social isolation. Some kids refuse treatment due to weight gain and begin decompensating, and the vicious cycle continues.

As a nurse, I felt moral distress, lacking power or authority to make decisions, and knowing that SGAs have many side effects, but that the benefits outweigh the risk, and keeping the child safe is a priority (Ohnishi et al., 2018).

After reading Vandenberghe et al. (2017), it is comforting to know that there is literature providing evidence of SGA side effects and cautioning providers to pay close attention to at risk patients (Vandenberghe et al., 2017). Vandenberghe et al. (2017) offered other solutions such as, behavioral interventions, diet, and physical activity in conjunction to SGAs, which allows providers to try different methods in treating adolescents (Vandenberghe et al., 2017).

Being in a prescribing/provider role in the near future, I feel I will be more cognizant of how I will prescribe SGAs. At the same time, I will keep in mind that SGAs are important when initially stabilizing a patient and keeping them safe, however I will choose more weight neutral SGAs for high risk Mets patients and offer other therapies adjunct to medication therapy.

Reference:

Ohnishi, K., Kitaoka, K., Nakahara, J., Va¨lima¨ki, M., Kontio, R., & Anttila, M. (2018). Impact of moral sensitivity on moral distress among psychiatric nurses. Nursing Ethics. https://doi-org.ucsf.idm.oclc.org/10.1177/0969733017751264

Vandenberghe, F., Najar-Giroud, A., Holzer, L., Conus, P., Eap, C.B., & Ambresin, A.E. (2017). Second generation antipsychotics in adolescent psychiatric patients: Metabolic effects and impact of an early weight change to predict long term weight gain. Journal of Child and Adolescent Psychopharmcology, XX(XX), 1-8.

I enjoyed reading everyone's posts related to SGA use in adolescents. I thought that all of you brought up good points that are important pieces of the conversation. In my clinical site, I see children and adolescents one day a week and I really haven't seen a lot of clients who take SGAs. Because of their side effect profile, we do not use them very often. Additionally, most of our clients are being seen for depression, anxiety, and/or PTSD and are on SSRI's. However, my preceptor and/or I see a few clients on SGA's and I have found that there is some focus on weight gain, but that this side effect deserves more attention. For example, my preceptor saw a client yesterday who is taking Abilify. He is overweight and has gained a few pounds since being on the medication, however, my preceptor and I spoke and this client's hallucinations are so distressing for him that my preceptor decided to increase the dose of the abilify. I think that side effects like weight gain can be such a difficult symptom to manage especially since the effects are more downstream instead of immediate. When do we decide to draw the line and change medications? I worked with the client and his mother around nutrition and physical exercise, but the client's father refuses to come into sessions and the client lives with him 50% of the time. One of my peers already mentioned this difference between working with children and working with adults, children are not always involved with the family meal planning so it is important to involve the family in these discussions. However, in my case and in many other of my clients, one parent is more invovled than the other and it makes it difficult to construct a plan that best meets the needs of the client. I appreciated this article because it helped give me a framework to manage my client's symptoms/side effects and I enjoyed learning from everyone on this thread about their experiences with these medications. 

Reflect on your experience or knowledge regarding use of SGAs in adolescents or youth.  

How does this article impact how you monitor adolescents or youth?  

Does this article trigger any new questions you have about SGAs in youth?

I have been doing my internship in a county mental health clinic for children and adolescents, so I have some growing experience with the use of SGAs in adolescents and transitional-age youth. I will be working with transitional age youth very soon, so I am quite interested in the metabolic risks of SGAs in this population. 

Unfortunately, unlike the baseline rate of obesity reported in the population used in the study we read for this session, many of the youth whom I or my preceptors have started on an SGA already had high BMIs. This is one reason why obtaining baseline metabolic lab studies is very important prior to starting treatment, and comparing these to results obtained over time. I recall two young, underweight men for whom we prescribed quetiapine, purposefully employing the side effects of weight gain and sedation in their favor. However, these patients will still need to be monitored at least yearly for metabolic changes and at each visit for excessive weight gain. 

We know that second-generation antipsychotics increase the risk for metabolic syndrome (MetS) However, we cannot tell a specific patient on a specific SGA that after specific length of time on said SGA that they have a specific numerical risk of MetS or a certain expected rate of weight gain. Furthermore, patients enter treatment with varying levels of predisposing risk for diabetes and atherosclerotic heart disease. Thus, all patients should be counseled, using the MI approach, and every visit, about diet and physical activity. My concern with my youth is that they may possibly be on SGAs for a long time, 

I went to a psychiatry conference last September and heard a presentation on metabolic syndrome and antipsychotics (unfortunately I cannot provide a reference as I did not purchase the slides and therefore do not have the speaker's name or even the title of the presentation). This speaker confirmed what Vandenberghe et al (2018) reported: namely, that weight gain early into treatment with SGAs is prognostic of risk for developing MetS in the future. We know from the CATIE trial that rates of continuous treatment for 18 months is very low for all antipsychotics studied , ranging from 18% for quetiapine to 36% for olanzapine. (Chen, McCombs, and Park, 2007). Subsequent studies have found similar rates of discontinuation (Chen, McCombs, and Park, 2007). Anecdotally, medication adherence is a big issue for all patients, but youth seems to pose additional threats to adherence. Therefore, if I see a 4% weight gain in a given adolescent patient on quetiapine within 3 months, I will counsel them on weight management and the risk for MetS, but I may not have high expectations that they will still be taking quetiapine in a year. I think that it is important to mindfully consider the risks and benefits of starting an SGA on a young person in the first place (especially for indications other than severe mental illness). Once on an SGA, it is important to approach the issue of metabolic syndrome holistically and individually for each patient. 

The question I am left with has to do with the duration of pharmacotherapy with an SGA and risk for MetS. The Vanderberghe retrospective study did not control for whether or for how long subjects had been on the antipsychotics, which I felt was a huge limitation. So, if I initiate quetiapine on a 16-year old male, and he takes it for 7 months and then self-discontinues it, does that length of treatment increase his lifetime risk of MetS independently of other risk factors he may have? This question is less salient if he has clear-cut schizophrenia or bipolar disorder (where the risks of the untreated illness may outweigh the risks of the medication) but what about in cases that I see often, where quetiapine is being used to target anger or insomnia primarily, with a BAD on the differential? 

References: 

Chen, L., Mccombs, J. S., & Park, J. (2008). Duration of Antipsychotic Drug Therapy in Real-World Practice: A Comparison with CATIE Trial Results. Value in Health, 11(3), 487-496. doi:10.1111/j.1524-4733.2007.00262.x

Vandenberghe, F., Najar-Giroud, A., Holzer, L., Conus, P., Eap, C. B., & Ambresin, A. (2018). Second-Generation Antipsychotics in Adolescent Psychiatric Patients: Metabolic Effects and Impact of an Early Weight Change to Predict Longer Term Weight Gain. Journal of Child and Adolescent Psychopharmacology. doi:10.1089/cap.2017.0038

Reflect on your experience or knowledge regarding use of SGAs in adolescents or youth.  

I have been working with severely mentally ill TAY during my second year of the PMHNP program and I’ve had the opportunity to closely follow/monitor an 18 year old male patient (CP) who was started on clozapine during his most recent hospitalization in late November 2017. Although none of the participants in the study were taking clozapine, it is one of the worst SGA metabolic offenders, so is quite relevant. CP was diagnosed with schizophrenia in late 2016 and has been hospitalized four times since then. Negative and catatonic symptoms are particularly debilitating for CP and he had minimal, if any, response to po olanzapine and IM aripiprazole, which is why he was started on clozapine during his 4th hospitalization.

CP has experienced significant improvement in his catatonic symptoms since starting clozapine, but he is still impaired by negative symptoms as well as regular auditory hallucinations. He has gained 32 lbs in 3 months, which is nearly 20% of his baseline weight of 164 lbs. Thankfully, CP’s lipid panel and HbA1c are within normal limits. We started him on Metformin 1000 mg/day about 45 days after he started on clozapine due to severe weight gain and to help prevent insulin resistance. I should also mention that CP experiences several other bothersome side effects of clozapine, but he continues to take it with the support of his family who fear for his health and safety if he is non-adherent.

My experience with CP has been incredibly challenging and eye-opening. I have been struggling to help him find creative ways to improve his diet and increase his level of physical activity. His negative symptoms seem to interfere with his ability to understand and/or implement small dietary and physical activity changes and his family’s living and financial situation make it even more difficult. Access to healthy food and safe options for physical activity are scarce due to these factors.

I’ve had some exposure to SGAs being prescribed to younger children for violent/disruptive behavior (primarily Risperdal) and noticed inconsistent metabolic screening practices among prescribers. I have also seen significant metabolic disturbances in a very short amount of time in younger children, which is likely to jeopardize their future health, as mentioned in the article.

How does this article impact how you monitor adolescents or youth?

Because of my clinical experience as a PMHNP intern, I plan to follow established guidelines for metabolic monitoring for all of my future patients on SGAs and to be very upfront with patients (and their parents when required/appropriate) about side effects and plans for monitoring. Some of the barriers to consistent metabolic monitoring are logistical considerations such as transportation to and from the lab, scheduling conflicts, fasting considerations, and long wait times at the lab. If resources are available at my future workplaces, I plan to utilize case management/care coordination services to help address these barriers. Even without additional resources, I plan to discuss barriers with patients and their families and help problem-solve to address them.

Does this article trigger any new questions you have about SGAs in youth?

I have a strong interest in the metabolic effects of SGAs in patients of all ages and interventions to consistently monitor for and treat subsequent metabolic disturbances. My comprehensive exam will explore existing research on the subject! One of the questions that I hope to answer through my literature review is whether or not there is a clinically meaningful difference in metabolic monitoring rates between psychiatric prescribers and primary care providers.