Dr Jocelyn Wood General Practitioner Nelson East Family Medical Centre Nelson 11:00 - 11:55 WS #87: Metabolic Monitoring on Anti-psychotic Medication 12:05 - 13:00 WS #98: Metabolic Monitoring on Anti-psychotic Medication (Repeated)
Cardiometabolic Monitoring on Antipsychotic Medication Dr Jocelyn Wood
Dr Jocelyn Wood • 0.5 FTE General Practice Nelson East Family Medical Centre • 0.3 FTE Clinical Director Community Mental Health, Nelson Marlborough District Health Board • NZMA GPC • Equally Well
Key Points • People who experience serious mental illness (SMI) - in particular schizophrenia - have significantly reduced life expectancy (15-25 years) compared to rest of population • Cardiovascular disease major contributor 40-50% • New MOH Cardiovascular Disease Risk Assessment and Management for Primary Care (February 2018) for SMI is recommended from age 25 years Don’t just screen - intervene
Outline 1. Physical health mortality and morbidity of people with SMI 2. Psychosis and cardiovascular risk 3. Cardiometabolic screening and intervention tool (Nelson) 4. Equally Well
People who experience mental health conditions have: People who experience mental health conditions Cunningham et al. NZMJ 2014 127:1394
Higher rates of physical health conditions and at a much earlier age Colorectal/ breast cancer (schizophrenia)
Psychotic illness and ↑ cardiovascular risk Accounts for 40-50% of premature deaths
MoH CVD risk assessment guidance Cardiovascular disease risk assessment and management for primary care 2018 guidelines include people with serious mental illness as a high-risk population. People who experience serious mental health problems; • have a significantly higher risk of dying from CVD than their general population counterparts. • Increased CVD risk is present at an earlier age than the general population. • Risk assessment should take place from the age of 25 for this group. • Current risk assessment tools are likely to underestimate the risk • There are inequities in assessing and managing CVD risk and CVD
Cardiovascular disease risk assessment and serious mental illness Table A1: Pooled estimates of relative risk of CVD in people with serious mental illness from meta-analyses published between 2000 and 2015 Diagnosis Relative risk* References Number of studies 1.53 (CI = 1.27 – 1.86) CVD Schizophrenia** 13 studies 1.71 (CI = 1.91 – 2.46) Stroke Fan et al 2013 (3,549,950 participants) 1.20 (CI = 0.53 – 1.53) CHD 1.56 (CI = 1.30 – 1.87) IHD Depression Charlson et al 2013 8 studies (35,000 participants) 2.69 (CI = 1.63 – 4.43) CHD Rugulies 2002 11 studies 1.46 (CI = 1.37 – 2.08) CVD Van der Kooy et al 2007 28 studies (80,000 participants) 1.90 (CI = 1.48 – 2.42) CHD Nicholson et al 2006 21 studies (124,509 participants) Key: CHD = coronary heart disease CI = confidence interval CVD = cardiovascular disease. IHD = ischaemic heart disease. * The risk estimates from single studies were adjusted for a variety of confounders, including age, sex, ethnicity, diabetes, hypertension, hyperlipidaemia, smoking, diet, physical exercise and alcohol consumption. ** While only one meta-analysis is identified in this table for people with psychosis, several large recent cohort studies found higher CVD risk and mortality from CVD for people with psychosis. https://www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care
Evidence shows gap is widening (Hayes, Marston, Walters, King & Osborn, 2017) and this is due to cardiovascular disease (CVD) mortality (Baxer et al., 2016) Te Pou o te Whakaaro Nui The physical health of people with mental health conditions and/or addictions Summary evidence update: December 2017
Potential causal pathways to increased CVD mortality for people with SMI
Antipsychotics and Weight Gain
Future Directions • Include psychotrophic medication as a risk factor for CVD and type II diabetes • Routinely monitor key physical health indicators for SMI: o Morbidity o Mortality
Evidence of the lipid paradox? Considering metabolic alterations in first episode psychosis Evidence of the lipid paradox? Considering metabolic alterations in first episode psychosis By permission of Dr Toby Pillinger MRCP @tobypill
The Natural History of Type 2 Diabetes
• Glucose homeostasis is altered from onset of psychosis, suggesting that patients are already at increased risk of diabetes. • Diabetic risk should be considered from onset of psychotic illness. Pillinger et al, 2017, JAMA Psych
Elevated fasting glucose and glucose post-OGTT in FEP ↑ fasting glucose in patients ES: g = 0.20; p = 0.03 ↑ glucose post -OGTT in patients ES: g = 0.61; p = 0.007
Elevated fasting insulin and insulin resistance in FEP ↑ fasting insulin in patients ES: g = 0.41; p < 0.001 ↑ insulin resistance in patients ES: g = 0.35; p = 0.001
Sensitivity Analyses BMI matching: FI and HOMA- IR ↑ Diet and exercising matching: FG ↑ Ethnicity matching: FG, glucose post- OGTT, FI, HOMA- IR ↑
• Raised cholesterol seen in established schizophrenia is not present at onset of psychosis • It is therefore secondary, and should be preventable!
↓ total cholesterol in FEP ES: g = -0.19; p = 0.005
↓ LDL cholesterol in FEP ES: g = -0.22; p = 0.001
↑ triglycerides in FEP ES: g = 0.14; p < 0.05
Low LDL Cholesterol: confounded by raised TGs/BMI? Friedwald equation: [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/2.2) Sensitivity analyses matching for TGs: ↓LDL cholesterol Sensitivity analyses matching for BMI: ↓LDL and ↓ total cholesterol
Antipsychotic naïve first episode psychosis is pro-inflammatory Could a pro-inflammatory state explain the metabolic alterations we are observing?
Antipsychotic naïve first episode psychosis is pro-inflammatory Pillinger et al 2018 (in submission)
Take home messages and future directions • Patients are already at increased risk of diabetes at onset of psychosis. • Raised cholesterol seen in schizophrenia is not present at onset of psychosis. • Could metabolic profiles be used as part of a diagnostic battery for psychosis? • Does inflammation play a role in observed metabolic alterations in psychosis? • Can addressing cardiometabolic alterations early in psychosis reduce mortality?
Clozapine therapy – theory (first 12 months)
2017 data – Elements of screening Completed Metabolic screening items in last 12 months 100 90 80 70 60 50 40 30 20 10 0 Bloods weight ECG BP Girth Height BMI Calc
A priority group: CVD risk assessment • The Ministry of Health updated the primary care CVD risk assessment guidelines
WITH SMOKING = Clozapine levels = Potential for relapse STOP OR REDUCE SMOKING = Clozapine levels = Risk of toxicity, seizures / sedation increases
2014: A Call to Action We acknowledge Te Tiriti O Waitangi as the founding document of Aotearoa New Zealand and the rights of all New Zealanders to reach their full health potential.
A Growing Collaborative In under 4 years, it has grown from 8 organisations to more than 100 !!
• Endorsed position paper • Board signed off on an Equally Well action plan • Special edition of GP Pulse • Supporting the “Well -being focused prescribing toolkit” • Equally Well policy paper
Increasing access to primary care: Canterbury’s Equally Well extended GP consults Four extended consultations per year for everyone who has been, or is expected to be, on antipsychotics for more than 3 months
✓ Get your organisation and/or professional body to endorse the consensus position paper ✓ Sign up for Equally Well e-news ✓ Be part of the discussions on the Equally Well online Loomio group ✓ Spend some time today thinking about one or two actions you can start tomorrow…
Thank You: • Jennifer Hassloch – QI, RN, NMDHB • Helen Lynch - RN, NMDHB • Helen Lockett – Equally Well • Toby Pillinger – King’s College London • Jane Kinsey – GM MHADSS, NMDHB
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