Managing metabolic side effects of psych meds

The issue can come up different ways

• Patient is started on a medication, there is a positive response however with the side effect of weight gain

• Patient comes to us on a medication regimen that works for them however they have gained weight on it

• Patient is found to have lab abnormalities indicating insulin resistance on a medication that otherwise works well for them

Psychiatric medications have the capacity to

• cause weight gain which way or may not reflect metabolic changes

• cause hyperglycemia

• cause insulin resistance

• cause lipid abnormalities

Can be dose-dependent or not

Can be time-dependent or not

Metabolic syndrome

= central obesity + hypertrigliceridemia + low HDL + elevated BP + elevated fasting glucose

= increased CAD risk

Antidepressants

SSRIs (Zoloft, Prozac, Luvox, Paxil), SNRIs, TCAs, Remeron

More likely to be time dependent

Antipsychotics

Abilify - counters this effect of other SGAs

Seroquel - less metabolic side effects than many other SGAs

Less likely to be time dependent: usually happens at the beginning of the titration

Mechanism of action:

H1 blockade + 5HT2c antagonism -> disruption of hypothalamic satiety control

Induction of lipogenic genes

Decreased energy expenditure

Ghrelin/leptin level changes

Differential diagnosis of weight gain

Sx of the actual illness (eg hyperphagia in atypical depression)

Disordered eating/ Overeating as a way of coping with emotions

Desired restoration of appetite (with tx of depression/anxiety)

Water retention

Hypothyroidism

Alcohol intake

Other medications patient is taking

Supplements patient is taking

Mitigating psychotropic-induced weight gain and metabolic side effect

Antidepressants

#1 Prevent by

Identifying high risk patients, use alternative tx

Opting for weight neutral options if pt has a history of weight gain eg. Celexa, Cymbalta, Wellbutrin

#2 Monitor regularly

#3 Please NOTICE when patient is complaining about this and Address

How to address psychotropic-induced weight gain and metabolic side effects

#1 recommend lifestyle modifications

• exercise (aerobic exercise lasting at least 4 hours a week total)

• diet (small, frequent meals, low glycemic index, minimization of simple sugars such as fructose, high protein, fiber and water intake)

• smoking cessation

#2 switching medications (Abilify, Prozac, Celexa, Cymbalta, Wellbutrin as appropriate)

#3 If pt wants to stay on the medication due to benefits, adding medications to manage side effects

-Weight gain: add bupropion if appropriate

-Elevated HgA1c; A1C 5.7 to 6.5 is prediabetes

→ check fasting glucose and fasting insulin. Lifestyle recs. Consider repeating bloodwork in 3-6 months depending on other risk factors

-Hyperglycemia +/- weight gain: metformin, conduct  workup and to eliminate other potential contributors

-Dyslipidemia (triglycerides and/ or LDL cholesterol level): manage