3.4 Metabolic adverse effects
Many antipsychotics are associated with weight gain, dyslipidaemia, hyperglycaemia and diabetes mellitus; these are also characteristics features of the metabolic syndrome. These effects increase the risk of adverse cardiovascular events and of early death.
Weight gain occurs most frequently during 6–12 months of starting antipsychotic treatment.
Antipsychotics vary in their risk for metabolic effects and weight gain, but the evidence is strongest for an association with second-generation antipsychotics, especially clozapine, olanzapine, and quetiapine. Schizophrenia is itself associated with an increased risk of insulin-resistant diabetes and cardiovascular disorders.
Factors which increase risk
Risk factors that may predispose patients to metabolic complications include obesity and personal or family history of diabetes, hyperlipidaemia, hypercholestrolaemia, thyroid disorder and pituitary adenoma.
Left untreated, hyperglycaemia can progress to ketoacidosis, coma and death.
The metabolic effects of antipsychotics might also be augmented by medicines with similar effects, such as corticosteroids (which can increase the risk of weight gain and diabetes).
Biochemical and clinical assessment at the start of treatment can identify those at greater risk of lipid disorders and hyperglycaemia; in such patients antipsychotics associated with a higher risk of metabolic effects are best avoided.
Modifiable risk factors for cardiovascular diseases (eg smoking, diet, excessive alcohol consumption, lack of exercise) should be addressed.
Monitoring during treatment allows prompt identification of adverse metabolic effects. Risk-reduction measures include advising patients and carers to watch out for features such as unusual thirst, increased urine output, unexplained weight changes, and weakness.
If a patient’s weight increases by over 2 kg in the first two weeks and the antipsychotic cannot easily be switched then strict dietary control should be considered.
If the antipsychotic cannot be withdrawn or treatment switched to a drug with lower risk of metabolic effects, then specific treatment should be instituted to manage the metabolic effects. Such treatment might include non-pharmacological and pharmacological measures against weight gain, hyperglycaemia and dyslipidaemia.
This learning module discusses noteworthy risks for antipsychotics. Summaries of product characteristics and the BNF should be consulted for a fuller account of the adverse effects and warnings for individual antipsychotics.
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