Monitoring metabolic side effects of psychotropic medication
Patients with severe mental illness suffer from poorer physical health and higher mortality, compared with the general population. This is due to a number of factors, such as problems accessing health services, self-neglect and genetics.
There is also a strong association between the use of psychotropic medication and an increased risk of developing a number of conditions associated with the onset of diabetes and cardiovascular disease, such as weight gain, increased glucose intolerance, dyslipidemia, and hypertension.
These factors make it extremely important to monitor patients on commencement and during treatment for severe mental illness.
QT prolongation has been linked to the sudden cardiac death syndrome and is particularly associated with typical antipsychotics, or high doses of antipsychotics. This effect can also be caused by physical health medicines such as domperidone and a congenital long QT syndrome prevalence of which is 1 in 5000 to 7000. It is now a NICE recommendation that all patients admitted to hospital for psychiatric treatment have ECGs done with particular attention given to the QT interval.
Hyperprolactinaemia is a recognised side-effect of typical antipsychotics, as well as risperidone and paliperidone. Its effects include menstrual disturbances, galactorrhoea and gynecomastia. Surprisingly, elevated prolactin levels have been found in neuroleptic naive patients with schizophrenia.
Benign liver and renal function abnormalities are common side-effects of most medicines but profound changes have been associated with the use of carbamazepine, valproate and lithium, which additionally requires 6-monthly thyroid and renal function tests.
A specific risk of antipsychotic use is the neuroleptic malignant syndrome (NMS) and the risk increases with the dose and number of antipsychotics used. Elevated body temperature and CPK can be the first signs of developing NMS.
Ensuring that all tests are done or obtained from a patient’s history on admission is very important. It may be the first occasion for a diagnosis as well as an opportunity to obtain baseline values to which future changes can be compared.
A clinical audit based on the above suggested monitoring standards taken from the Maudsley Prescribing Guidelines was carried out in a hospital and the results were that many of the tests were done irregularly or not at all. The most commonly recorded values were blood pressure and weight. Other tests were recorded inconsistently and there were no prolactin or CPK baseline values. It was also noted that tests results were often not filed correctly, making them difficult to find. Since then, a more robust approach to screening and monitoring has been implemented at the hospital as a result of the audit evaluation.
The CQC Annual Report on the Mental Health Act for 2013 stated that commissioners should make sure mental healthcare providers have the infrastructure in place to monitor and address people’s physical health needs which should lie at the core of all mental health services.
Photo by Gertbuschmann [Public domain or Public domain], via Wikimedia Commons