Antipsychotic Metabolic Screening in Kids Remains Shockingly Low

Fran Lowry

March 18, 2015

Metabolic screening rates for children and adolescents starting treatment with second-generation antipsychotics remain nearly as low as they were before the American Diabetes Association (ADA) first issued its recommendations for such screening in 2004, new research shows.

Studies, both randomized and observational, show that second-generation antipsychotics cause a significant increase in children's body mass index and may pose serious metabolic risks because of these patients' hormonal and developmental status.

Still, the prescribing of second-generation antipsychotics continues to increase among youth, write John G. Connolly and colleagues from Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

The study was published online March 2 in Psychiatric Services.

Small Uptick

The guidelines issued by the ADA, in conjunction with the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity, recommend that prescribers of second-generation antipsychotics test patients' blood glucose at baseline, 12 weeks after the start of the medication, and once a year thereafter.

Shortly after the guidelines were issued, there was a small increase in glucose testing, but further research showed that monitoring was still underused in adult Medicaid beneficiaries and commercially insured adults, the investigators write.

In the current study, the authors evaluated the frequency of both blood glucose and hemoglobin A1c (HbA1c) testing among commercially insured children and adolescents who began their first course of second-generation antipsychotics around the time the 2004 guidelines were issued, and in the following 8 years.

They identified 52,407 patients aged 5 to 18 years, (mean age, 13.14 years; 61% male) from a large, nationwide, commercial insurance claims database (United Healthcare) for the period January 1, 2003, through December 31, 2011.

The patients were all new users of the following second-generation antipsychotics: risperidone (Risperdal, Janssen Pharmaceuticals, Inc), aripiprazole (Abilify, Otsuka Pharmaceutical Co, Ltd), olanzapine (multiple brands), quetiapine (Seroquel, AstraZeneca Pharmaceuticals LP), and ziprasidone (Geodon, Pfizer Inc).

The second-generation antipsychotic that was most frequently prescribed during this period was risperidone, with 21,319 new users. During the same period, 13,464 new users started aripiprazole, and 12,315 started quetiapine.

The most common diagnostic code in the study population was affective psychosis, which includes bipolar disorder and major depressive affective disorder.

The analysis showed that the proportion of patients receiving a glucose test before the start of antipsychotics increased from 17.9% in 2003 to 18.9% in 2004. In the same period, testing after the start of antipsychotics increased from 14.7% to 16.6%.

However, the slight increase in glucose testing was not sustained, and the proportion of children and teens being tested dropped in the following years before rising again in 2008 to 16.2%.

By 2011, the proportion of patients starting second-generation antipsychotics who had a glucose test within 6 months of initiation was 17.5%.

The trends in HbA1c testing were similar, although at a lower level, the researchers report.

From 2003 to 2004, preinitiation HbA1c testing rose from 0.4% to 0.7%. During the same period, postinitiation HbA1c testing increased significantly from 0.6% to 1.1%.

In 2011, both pre- and postinitiation HbA1c testing rates were highest, when 2.0% received a preinitiation test and 2.7% received a postinitiation test.

Large Diabetes Risk

Although glucose testing rates improved in 2008, they remained suboptimal throughout the study period.

"Considering the guidelines, we found that the average metabolic screening rate over the study period was too low ― around 16% for glucose tests and 1.5% for HbA1c tests," the authors write.

The finding of low metabolic screening rates "is in line with surveys of practicing physicians, which show a contrast between high awareness of metabolic risks of second-generation antipsychotics and low metabolic monitoring practices," they add.

The authors suggest that barriers to compliance with treatment guidelines could include a lack of familiarity or disagreement with the ADA recommendations as well as the severity of the patient's condition.

"The importance of addressing these barriers to compliance is underscored by a recent study in a pediatric Medicaid population, which found that use of second-generation antipsychotics with children and adolescents ages six to 17 conferred a threefold higher risk of type 2 diabetes," they note.

The authors also write that their results could be explained by the parallel increase in childhood obesity that occurred during the same period.

In addition, labeling changes to olanzapine and quetiapine in 2009, which highlighted the importance of metabolic screening with the second-generation antipsychotics, could have prompted the small increase in screening that was noted toward the end of the study period, they suggest.

The low metabolic screening rates are concerning, they write.

"Uncontrolled blood sugar among children has serious consequences, such as weight gain and type 2 diabetes, particularly among those with mental illness, who are already at higher risk of poor health outcomes, thus further emphasizing the importance of metabolic screening," they write.

How to Improve Screening

Commenting on the study for Medscape Medical News, David C. Rettew, MD, agrees that metabolic monitoring is important, because second-generation antipsychotics carry the risk for diabetes and high cholesterol and other serious side effects.

Dr David Rettew

"These related problems are often called metabolic syndrome. Since these conditions may not cause physical symptoms, we need blood tests to monitor whether or not they may be developing," said Dr Rettew, from Vermont College of Medicine, Burlington.

To improve screening, a number of measures have been proposed, he said.

"These ideas range from simply improving education to physicians about the guidelines all the way to more regulatory actions, such as preventing a prescription from being filled unless screening is done or a justification for not doing it is provided.

"In this era of electronic medical records [EMR], one thing that could also be helpful and is not punitive is to have the EMR send an electronic reminder to a prescriber that the screening needs to be done at regular intervals," Dr Rettew said.

The study was funded by Brigham and Women's Hospital and Harvard Medical School. The authors of the study and Dr Rettew report no relevant financial relationships.

Psychiatr Serv. Published online March 2, 2015. Abstract

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