171 - References

References

Schizophrenia and related psychoses CHAPTER 1 recommended by NICE for secondary prevention of cardiovascular events.61 NICE makes no recommendations on target levels for primary prevention but recent advice promotes the use of statins for anyone with a >10% 10-­year risk of cardiovascular disease.61 Coronary heart disease and stroke risk can be reduced by a third by reducing cholesterol to as low as 3.5mmol/L. When triglycerides alone are raised, diets low in saturated fats and the taking of fish oil and fibrates are effective treatments,31,62,63 although there is no proof that mortality is reduced. Such patients should be screened for impaired glucose tolerance and diabetes. If moderate to severe hyperlipidaemia develops during antipsychotic treatment, a switch to another antipsychotic medication less likely to cause this problem should be considered in the first instance. Although not recommended as a strategy in patients with treatment-­resistant illness, clozapine-­induced hypertriglyceridaemia has been shown to reverse after a switch to risperidone.64 This may hold true with other switching regimens but data are scarce.65 Aripiprazole and other D2 partial agonists seem to be the treatments of choice in those with prior antipsychotic-­induced dyslipidaemia (lumateperone and ziprasidone are options outside the UK).20,66 There is evidence to suggest that adjunctive aripiprazole may have beneficial effects on measures of plasma cholesterol and triglycerides when combined with clozapine or olanzapine19,49,67 and that metformin added to antipsychotic medication may improve total cholesterol and triglyceride levels49,68 (see Buzea et al. 202257 and the ‘BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment’49 for discussion of the potential risks and benefits of these two strategies). Summary of monitoring Medication Suggested monitoring schedule Clozapine Fasting lipids at baseline then every 3 months for a year, then annually Olanzapine Other antipsychotic medications Fasting lipids at baseline, 3 months, and then annually66 References

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