Michael J. Bailey, M.D. OptumHealth Public Sector
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1 Michael J. Bailey, M.D. OptumHealth Public Sector
2 LIHP Quality Charter To ensure the quality of care delivered to enrollees in San Diego County Assistance Programs, such as County Medical Services (CMS) and the Low Income Health Program (LIHP), and to assure the most cost-effective and appropriate utilization of resources which promote positive patient outcomes.
3 LIHP Quality Projects Designed to evaluate and improve care given to enrollees An evidence-based approach utilizing best practice guidelines to enhance outcomes
4 Atypical Antipsychotic Medication Project Background Life expectancy in schizophrenia is reduced by 20% Non-psychiatric or physical health issues contribute to 60% of the risk Life style choices: Poor Diet Lack of Exercise High rates of smoking Limited health care access Increased prevalence of Type-II Diabetes and cardiovascular disease
5 Prevalence of Cardiovascular Comorbidities in Schizophrenia Prim Care Companion J Clin Psychiatry. 2003; 5(1): 6 14.
6 Newly Diagnosed Diabetes During New Antipsychotic Monotherapy Annualized Incidence of Diabetes Mellitus in Specific Antipsychotic Treatment Cohorts
7 Atypical Antipsychotic Medication Project Background Schizophrenia is a risk factor for diabetes Atypical Antipsychotic Medications (AAMs) have metabolic consequences as well Net Effect 24% - 53% of individuals with schizophrenia meet criteria for metabolic syndrome
8 Antipsychotic medications Generic name Trade name Year approved 1 st Generation Chlorpromazine Thorazine Perphenazine Trilafon Trifluoperazine Stelazine Thiothixene Navane Haloperidol Haldol Fluphenazine Prolixin 2nd Generation Clozapine Clozaril 1989 Risperidone Risperdal 1993 Olanzapine Zyprexa 1996 Quetiapine Seroquel 1997 Ziprasidone Geodon 2001 Aripiprazole Abilify 2002 Paliperidone Invega 2007 Asenapine Saphris 2009 Iloperidone Fanapt 2009 Lurasidone Latuda 2010
9 SGA s and Metabolic Abnormalities Weight Risk for Worsening Drug Gain Diabetes Lipid Profile Clozapine (Clozaril) Olanzapine (Zyprexa) Risperidone (Risperdal) ++ D D Quetiapine (Seroquel) ++ D D Aripiprazole* (Abilify) +/- - - Ziprasidone* (Geodon) +/ = increase effect; - = no effect; D = discrepant results. *Newer drugs with limited long-term data. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care 27, , 2004.
10 Metabolic Changes with Antipsychotics Decrease in insulin sensitivity Not related to: A decrease in insulin secretion or production Serotonin 5-HT 2c antagonism Possible connection: Histamine H 1 receptors Neuropsychopharmacology Jun;33(7): J Clin Psychiatry Jun;60(6): Physiol Behav Sep 26;104(4):590-8.
11 Atypical Antipsychotic Medication Project Background Definition of Metabolic Syndrome Hypertension (> 140/90 mm/hg) Central obesity Glucose intolerance/insulin resistance Dyslipidemia Reduced HDL cholesterol Increased triglycerides
12 Risk Factors for Metabolic Syndrome Genetic Factors Family history of type 2 diabetes or gestational diabetes Race Hispanic and Asian backgrounds Age Risk increases with age 10% in people in their 20 s 40% in their 60 s Obesity A BMI > 25 Other Diseases Hypertension Cardiovascular Disease Polycystic Ovary Syndrome Metabolic Syndrome: Risk factors MayoClinic.com
13 Atypical Antipsychotic Medication Project Background Metabolic syndrome is reversible. Diet Exercise Medications Antihypertensives Cholesterol lowering drugs Hypoglycemic meds (metformin, glipizide, etc) Wu R, et al. Metformin Addition Attenuates Olanzapine-Induced Weight Gain in Drug-Naïve First-Episode Schizophrenia Patients: A Double-Blind, Placebo-Controlled Study. Am J Psychiatry 2008; 165: Klein DJ, et al. A Randomized, Double-Blind, Placebo-Controlled Trial of Metformin Treatment of Weight Gain Associated with Initiation of Atypical Antipsychotic Therapy in Children and Adolescents. Am J Psychiatry 2006; 163:
14 Atypical Antipsychotic Medication Project Background Screening for metabolic syndrome is offered infrequently and often incompletely in the psychiatric population A variety of screening methods take place Screening only occurs in 4 41% of psychiatric patients on antipsychotic drugs Barnes TR, et al. A UK Audit of Screening for the Metabolic Side Effects of Antipsychotics in Community Patients. Schizophr Bull. 2007;33(6):
15 Atypical Antipsychotic Medication Project Interventions Screening Recommendations Glucose levels > 110mg/dl Abdominal Obesity defined as: > 40 in males > 35 in females Not associated with: Specific diagnosis Specific antipsychotic regimen Gender or ethnicity Straker D, et al: Cost-effective Screening for the Metabolic Syndrome in Patients Treated with Second- Generation Antipsychotic Medications. Am J Psychiatry 2005;162:
16 Atypical Antipsychotic Medication Project Goals Encourage utilization of PCP visits and connection to Medical Home for enrollees filling a prescription for atypical antipsychotic medications for the purpose of screening all of these individuals for metabolic syndrome.
17 Atypical Antipsychotic Medication Project Goals PCPs or mental health providers will check LDL and glucose levels at baseline and every 6 months for individuals filling a prescription for atypical antipsychotic medications. Facilitate PCP treatment of any abnormal LDL and glucose levels for individuals filling a prescription for atypical antipsychotic medications.
18 Atypical Antipsychotic Medication Project Interventions Encourage PCP visits and connection to Medical Home for enrollees Monitor weight/bmi & abdominal girth Check LDL and glucose levels every 6 months Facilitate PCP treatment of any abnormal LDL and glucose levels Facilitate diagnosis and treatment of metabolic syndrome in these individuals Encourage communication between the PCP and the psychiatrist
19 Atypical Antipsychotic Medication Project Interventions Once a new prescription for an antipsychotic medication is filled, the LIHP will notify the primary care provider (PCP)/medical home via in a monthly medical director report. PCP may follow-up with further inquiry and screening tests
20 Atypical Antipsychotic Medication Project Interventions The Primary Care Provider Role: Engage Schedule patients on these meds for follow-up & screening labs Develop rapport, take an active interest in their lifestyle Educate Handout on Metabolic Syndrome Diet and Exercise Interventions Monitor Weight, BMI, Abdominal Circumference Labs: glucose, LDL, HDL, triglycerides Treat As indicated
21 From: The Metabolic Syndrome JAMA. 2006;295(7): doi: /jama Date of download: 3/28/2013 Copyright 2012 American Medical Association. All rights reserved.
22
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