178 - Monitoring

Monitoring

176 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ­glucose homeostasis. Aripiprazole may even reverse diabetes caused by other drugs73 (although ketoacidosis has been reported with aripiprazole).74–76 Further, studies have not found amisulpride or aripiprazole to be associated with a significantly greater risk of diabetes.61,77,78 So, these three drugs (amisulpride, aripiprazole and ziprasidone) are recommended for those with a history of, or predisposition to, diabetes mellitus or as an alternative to other antipsychotic medications known to be diabetogenic. Data suggest that neither lurasidone79,80 nor asenapine81,82 has any effect on glucose homeostasis. Likewise, early data on brexpiprazole83,84 and cariprazine85–87 suggest minimal effects on glucose tolerance. Thus, for patients developing prediabetes or diabetes who are being treated with clozapine, olanzapine or quetiapine, switching to antipsychotic medications with a lower cardiometabolic risk, such as aripiprazole, brexpiprazole, cariprazine, lurasidone or ziprasidone, has been recommended.88 Lumateperone appears to have no effect on glucose parameters89 but clinical experience is limited. Predicting antipsychotic-­related diabetes The risk of diabetes is increased to a much greater extent in younger adults than in the elderly90,91 (for whom antipsychotic medication may show no increased risk).92 Patients with first-­episode schizophrenia seem particularly prone to the development of diabetes with a variety of antipsychotic medications.93–95 During treatment, rapid weight gain and a rise in plasma triglycerides seem to be predictive of the development of diabetes.96,97 Monitoring of abnormal glucose metabolism is particularly warranted in those with obesity or hypertriglyceridaemia.42 Monitoring Diabetes is a growing problem in western society and has a strong association with obesity, (older) age, (lower) educational achievement and certain ethnic groups.98,99 Diabetes markedly increases cardiovascular mortality, largely as a consequence of atherosclerosis.100 Likewise, the use of antipsychotic medication also increases cardiovascular mortality.101–103 Intervention to reduce plasma glucose levels and minimise other risk factors (obesity, hypercholesterolaemia) is therefore essential.104 There is no clear consensus on diabetes monitoring practice for those receiving anti­ psychotic medication,105 and the recommendations in formal guidelines vary considerably.106 Given the previous known parlous state of testing for diabetes in the UK13,107–109 and elsewhere,110 arguments over precisely which tests are done and when seem to miss the point. There is an overwhelming need to improve monitoring by any means and so any tests for diabetes are supported – urine glucose and random plasma glucose included. Ideally, though, all patients should have oral glucose tolerance tests (OGTT) performed as this is the most sensitive method of detection.111,112 Fasting plasma glucose (FPG) tests are less sensitive but recommended.113 Any abnormality in FPG should provoke an OGTT. Fasting tests are often difficult to obtain in acutely ill, disorganised patients, so measurement of random plasma glucose or glycated haemoglobin (HbA1c) may also be used (fasting not required). HbA1C is recognised as a useful tool in detecting and monitoring diabetes.7 In the UK, NICE114 recommendations for monitoring people with a psychotic disorder, treated with antipsychotic medication, include the measurement of plasma glucose or HbA1C 3 months after starting treatment and then annually (Table 1.39).