Antipsychotic-Related Metabolic Testing Falls Far Short

Liam Davenport

May 26, 2016

Although the majority of patients with serious mental illness who are prescribed antipsychotics undergo annual glucose testing to screen for diabetes, fewer than half receive regular testing of lipid levels for cardiometabolic disorders, a statewide analysis of Medicaid claims data indicates.

Elaine H. Morrato, DrPH, MPH, Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, in Aurora, and colleagues found that among more than 9000 patients taking the drugs, almost 80% received annual glucose testing, but just over 40% underwent lipid testing.

"Metabolic risk information on antipsychotics has been broadly disseminated over the past decade. Still, as is often the case in the diffusion of a new practice, knowledge does not necessarily equal behavioral change," the authors write.

The research was published online May 11 in JAMA Psychiatry.

Mixed Messages

The goal of the study was to "inform national and state policymakers, clinical practitioners, patient advocacy groups, and other individuals responsible for ensuring that adults with serious mental illness receive appropriate clinical preventive services."

The team conducted a retrospective study and analyzed administrative claims data from 9316 new users of oral second-generation antipsychotics in the Missouri Medicaid program between 2010 and 2012. Secondary analysis of survey data of prescriber knowledge, attitudes, and behavior was performed for a subset of 1813 participants.

The antipsychotics included aripiprazole, asenapine maleate, clozapine, iloperidone, lurasidone hydrochloride, olanzapine, paliperidone, quetiapine fumarate, risperidone, and ziprasidone. These drugs were classified as being associated with high or low/medium metabolic risk on the basis of data from the US Food and Drug Administration (FDA) and the American Diabetes Association (ADA).

The patients were aged 18 to 64 years. The mean age was 37.6 years, 35.8% were men, and 19.9% were diagnosed as having schizophrenia or bipolar disorder. Antipsychotics associated with a low/medium metabolic risk were prescribed in 90.9% of cases.

Prescribing was evenly distributed across specialty setting, with 24.3% of patients prescribed antipsychotics in a community mental health center (CMHC), 27.6% in a non-CMHC behavioral health setting, 24.3% in primary care, and 23.8% in settings classifed as other/unknown.

The team found that annual glucose testing was performed in 79.6% of participants, whereas lipid testing was performed in 41.2%. The proportion of patients receiving no glucose or lipid testing was similar across prescriber settings.

In adjusted analyses, lower rates of failure to perform glucose testing were associated with older age (odds ratio [OR], 0.64 for patients aged 40-49 years vs 18-29 years), a diagnosis of schizophrenia or bipolar disorder (OR, 0.55), cardiometabolic comorbidity (OR, 0.28 for dyslipidemia and 0.59 for hypertension), and greater outpatient utilization (OR, 0.33 for >6 encounters vs none).

The reasons for failure to perform lipid testing were different from those for glucose testing. Schizophrenia or bipolar disorder was not associated with testing (OR, 0.90); failure to test was associated with an alcohol or substance abuse disorder (OR, 1.13) and having an index prescriber who wrote fewer antipsychotic prescriptions (OR, 1.20 for <400 vs 400-1499 prescriptions).

Failure to perform lipid testing in the outpatient setting was also associated having more emergency department encounters and hospitalizations (OR, 1.22 for 6-12 encounters vs 0-5 encounters).

In addition, younger patients with fewer chronic conditions were less likely to undergo annual testing. The researchers believe rates of glucose and lipid testing in this patient population may related to conflicting messages from guidelines issued by various organizations as to whether this younger group should be screened.

"Consistency and redundancy in messaging about the advisability of annual screening is important, and professional associations, federal agencies, and health care organizations should reach consensus on testing recommendations so that they reinforce the same message," the investigators write.

For example, the ADA, the American Psychiatric Association Consensus Conference, and FDA drug labeling call for screening in all patients receiving antipsychotics, whereas the Health Plan Employer Data and Information Set prioritize adults with schizophrenia or bipolar disorder.

Furthermore, the US Preventive Services Task Force (USPSTF) and ADA general guidelines recommend that screening be based on age, ethnicity, and risk factors, although mental illness is not explicitly included as a risk factor.

The issue, Dr Morrato believes, is that "different organizations look at it through the lens of the groups they target."

She told Medscape Medical News that the psychiatry community might focus on people with more serious mental illness, whereas the ADA and the USPSTF will look broadly at the general population. The FDA "is going to look at it through the lens of the particular therapeutic user, and that is often the user that has an indication that's been approved."

To resolve the issue, the value of screening needs to be established in this younger group, particularly in terms of the number needed to screen to identify new cases of diabetes and dyslipidemia.

"I think a health system is going to look at the efficiency, just like you would for any public health program, of a metabolic screening program and ask: 'Does the extra effort warrant it in this age group?' I think there's probably some more evidence needed to fully support that," she said.

More broadly, the efficiency and cost-effectiveness of metabolic screening for all age groups receiving antipsychotics should be confirmed. That is the subject of several studies, including one by Dr Morrato's team.

This is important, she said, because, for state Medicaid directors with limited resources, the question is: "If I try to expand my screening programs, is it worth it? Am I identifying new cases? Will it lead to reduced metabolic risk and better health outcomes?"

Another important question is whether existing, proven interventions to reduce the risk for diabetes and metabolic disorders for the general population can be adapted to persons with mental illness.

Noting that the National Institute of Mental Health has called for research into such interventions, Dr Morrato said: "We don't have to recreate the wheel. We have other kinds of programs that are used to improve these risks in the general population, so how can we adapt them for those with serious mental illness?"

"No Free Lunch"

Commenting, Thomas W. Sedlak, MD, PhD, assistant professor of psychiatry and behavioral health at Johns Hopkins University School of Medicine, in Baltimore, Maryland, said that it was a good study on an important topic and that he would expect few differences had patients insured through Medicare been included.

He said that an "encouraging finding was that doctors seem to be doing a better job of being mindful of the diabetes risk."

However, he noted that "it's important to make the doctors accountable and remind them that, while they're doing a better job with the glucose, they're not doing as well with the lipids." He believes that people are thinking "too quickly" about diabetes and not enough about dyslipidemia disorders.

Dr Sedlak added that it is assumed that second-generation antipsychotics have fewer adverse effects compared with second-generation agents that are associated with drug-induced parkinsonism and tardive dyskinesia.

However, he notes that adverse effects associated with second-generation antipsychotics, such as obesity, metabolic syndrome, and cardiovascular disease, cannot be taken "lightly, and I think you can no longer really say that the second generation are just blindly safer than the older medications.

"As far as we know, tardive dyskinesia isn't really lethal, but a heart attack, because you have diabetes and cardiovascular disease, is, and it will shorten your lifespan. So I think this is a nice study that underlines the importance of considering these major side effects with this whole class of medications.

"We do have a lot of antipsychotics now, close to 20 of them, but there's no free lunch, so to speak, and some of the really good ones carry a high risk of weight gain or sedation, and some of the ones that are low on side effects just may not be as effective in some more severe cases. It's still an ongoing quest to find a great drug that carries the same degree of morbidity," Dr Sedlak added.

Research funding was obtained through grants from the National Institutes of Health and the Association for Healthcare Research and Quality. Dr Morrato has received consulting fees and travel funds from Merck and Janssen Pharmaceutical. Dr Morrato and a coauthor have received research funding from Janssen Pharmaceuticals.

JAMA Psychiatry. Published online May 11, 2016. Abstract


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