Metabolic Syndrome

Primer

Metabolic Syndrome is a group of conditions (including increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels) that occur together. This increases the risk of heart disease, stroke and diabetes. Of psychotropic medications, the risk is greatest with antipsychotics.

Mechanism

  • Antipsychotics are thought to cause metabolic syndrome through a variety of etiologies, including histamine (H1) antagonism, increased appetite, and/or the alteration of insulin sensitivity which then directly impairs metabolic regulation.

Antipsychotics

Antipsychotics and Risk for Weight Gain

Adapted from: Pringsheim, T. et al. Physical Health and Drug Safety in Individuals with Schizophrenia. Canadian Journal of Psychiatry. 2017;62(9):673-683.
Category Risk of Weight Gain (%) Antipsychotic
Lower <12 Aripiprazole, asenapine, and ziprasidone
Intermediate 10-24 Lurasidone, other first generation antipsychotics, paliperidone, perphenazine, quetiapine, and risperidone
Higher >24 Chlorpromazine, clozapine, and olanzapine

Monitoring

  • Patients with first-episode presentation of psychosis should be closely monitored for metabolic side effects.[1]

Antipsychotic Monitoring

Adapted from: Pringsheim, T. et al. (2017) Physical health and drug safety in individuals with schizophrenia. The Canadian Journal of Psychiatry, 62(9), 673-683.
Initiation 1 month after initiation 3 months after initiation Then annually
Electrolytes, Cr, LFTs, TSH ✓ As clinically indicated As clinically indicated As clinically indicated
Fasting plasma glucose ✓ As clinically indicated ✓ ✓
HbA1c ✓ - ✓ ✓
Lipid panel (total cholesterol, LDL, HDL, triglycerides) ✓ As clinically indicated ✓ ✓
Body mass (BMI) ✓ ✓ ✓ ✓
Blood pressure (BP) ✓ As clinically indicated ✓ ✓
Extrapyramidal symptom (EPS) exam ✓ ✓ ✓ ✓
Endocrine function history (gynecomastia, galactorrhea, libido) ✓ - ✓ ✓
Prolactin If clinically indicated If clinically indicated If clinically indicated If clinically indicated
ECG (QT monitoring) If clinically indicated (some clinicians will order this routinely as a baseline) - If on multiple QTc-prolonging medications
(or if clinically indicated) 		As clinically indicated, or yearly
Smoking history ✓ - ✓ ✓

Management

  • There has been increasing evidence that the use of metformin can reduce weight gain and dyslipidemia.[2][3]
  • Lifestyle interventions such as diet, exercise, and behavioural change is also important.[4]

Guidelines

Resources

For Patients
For Providers
Articles
Research

References

1) Correll, Christoph U., et al. Cardiometabolic risk in patients with first-episode schizophrenia spectrum disorders baseline results from the RAISE-ETP study. JAMA psychiatry 71.12 (2014) 1350-1363.
2) Pringsheim, T., Kelly, M., Urness, D., Teehan, M., Ismail, Z., & Gardner, D. (2017). Physical health and drug safety in individuals with schizophrenia. The Canadian Journal of Psychiatry, 62(9), 673-683.
3) Holt, R. I. (2019). Association between antipsychotic medication use and diabetes. Current diabetes reports, 19(10), 96.
4) Pringsheim, T., Kelly, M., Urness, D., Teehan, M., Ismail, Z., & Gardner, D. (2017). Physical health and drug safety in individuals with schizophrenia. The Canadian Journal of Psychiatry, 62(9), 673-683.