Guidelines for metabolic monitoring

Metabolic Monitoring Tool incorporates recommendations from various guidelines and
consensus statements regarding the assessment and ongoing monitoring for metabolic syndrome in
patients receiving antipsychotic medications. It is recommended that the Metabolic Monitoring
Tool be filled in whenever a client is started on an atypical antipsychotic. A new form should be
started when there is a switch in medication.
Frequency of measurement of the specific parameters
is indicated on the Metabolic Monitoring Tool. Medication associated changes are most likely to occur
within the first year of treatment. Monitoring can occur annually thereafter. True baseline refers to an
antipsychotic naïve client being assessed at the time of first treatment. Current baseline refers to status
at the time of the introduction of the medication listed as the current antipsychotic. If a client declines
to engage in monitoring, this may be noted with a “D” in place of the values for a given assessment
time period. A space is provided on the form for a patient’s physician’s initials indicating that the
results have been reviewed.
2. Individuals with schizophrenia and mood disorders appear to have a higher risk of developing metabolic syndrome. Antipsychotics, particularly atypical antipsychotics have been associated with metabolic syndrome. 3. Individuals with metabolic syndrome are at high risk of both type 2 diabetes and cardiovascular disease and their associated increased morbidities and mortalities. 4. Metabolic syndrome has been defined as: Table 1 – The new International Diabetes Federation (IDF) definition:

According to the new IDF definition, for a person to be defined as having the metabolic syndrome
they must have:
Central obesity (defined as waist circumference ≥ 94 cm for Europid men and ≥ 80 cm for Europid
women, with ethnicity specific values for other groups)

plus any TWO of the following four factors:

raised TG level: ≥ 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality
reduced HDL cholesterol: < 40 mg/dL (1.0 mmol/L) in males and < 50 mg/dL (1.3 mmol/L)
in females, or specific treatment for this lipid abnormality
raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mmHg, or treatment of
previously diagnosed hypertension
raised fasting plasma glucose (FPG): ≥ 100 mg/dL (5.6 mmol/L), or previously diagnosed
type 2 diabetes
If above 5.6 mmol/L or 100mg/dL, OGTT is strongly recommended but is not necessary to define 5. The atypical antipsychotics vary in their tendency to cause metabolic abnormalities. Table 2 – Atypical antipsychotics and metabolic abnormalities:
Ô Newer agents with limited long-term data VCHA, Vancouver Community Mental Health Services 6. Although there is less information available regarding the metabolic syndrome and other psychiatric medications, significant weight gain has been reported with several different mood stabilizers and antidepressants. Clinicians may want to use the Metabolic Assessment Tool in these situations as well. 7. The health risk of diabetes and cardiovascular disease varies depending on several modifiable and non-modifiable factors. Some of the major risk factors included below are listed on the Metabolic Monitoring Tool in checklist format. • • High blood pressure • Male gender • Personal or family history of diabetes/CVD • Aboriginal, Hispanic, South Asia, Asian or African descent 8. Accumulation of risk factors increases the likelihood of a poor health outcome and it may be valuable to assess risk when making decisions about drug therapy. Although not standardized, one stratification scheme is as follows: Table 3 – Risk:
9. All clients should be advised of the metabolic risks of atypical antipsychotics. When appropriate, education about the signs and symptoms of diabetes, as well as the life-threatening condition of diabetic ketoacidosis, should be given. Table 4 – DKA clinical presentation:
• Polyuria, polydipsia • Weight loss • Rapid respiration • Clouding of sensorium, even coma 10. Ideally, all clients should receive counselling about healthy lifestyles including smoking cessation, diet and physical activity. High-risk individuals may require referral to specialized services. 11. Abnormalities in glucose, blood pressure of lipids need to be assertively treated. This may require liaison with GP/specialist(s) and other supports for the client to facilitate maintenance of appointments etc. 12. The decision to switch antipsychotics or other therapy because of metabolic abnormalities will need to be individualized. As a general guideline, switching to an alternative agent should be considered if a patient gains > 5% of his or her baseline weight at any time during therapy or if there is worsening of glycemia or dyslipidemia. There are many other factors to consider, such as degree of risk, psychiatric history, treatment history, client variables etc. A careful risk-benefit assessment should be undertaken. 13. Suggested interventions shown on the Tool may be checked off when they are conducted. Individual clinicians may choose to use all or some or none of these suggestions depending on the client and situation. When and how these interventions are applied will be up to the treating team. The checklist format is provided for ease of recording and as a reminder. VCHA, Vancouver Community Mental Health Services


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