Dr Jocelyn Wood General Practitioner Nelson East Family Medical - - PowerPoint PPT Presentation

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

• n 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:

Cunningham et al. NZMJ 2014 127:1394

People who experience mental health conditions

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 Schizophrenia** 1.53 (CI = 1.27–1.86) CVD 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 Depression 1.56 (CI = 1.30–1.87) IHD 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:
• Morbidity
• Mortality

Evidence of the lipid paradox?

Considering metabolic alterations in first episode psychosis

By permission of Dr Toby Pillinger MRCP @tobypill

Evidence of the lipid paradox?

Considering metabolic alterations in first episode psychosis

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
• nset 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?

Pillinger et al 2018 (in submission)

Antipsychotic naïve first episode psychosis is pro-inflammatory

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

10 20 30 40 50 60 70 80 90 100 Bloods weight ECG BP Girth Height BMI Calc

Completed Metabolic screening items in last 12 months

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

• rganisations 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,

• r 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