Podcast
Questions and Answers
Patients on antipsychotic medications should only report symptoms of diabetes if they experience fatigue.
Patients on antipsychotic medications should only report symptoms of diabetes if they experience fatigue.
False
Switching to aripiprazole or ziprasidone can potentially reverse changes in glucose tolerance in patients taking antipsychotic medications.
Switching to aripiprazole or ziprasidone can potentially reverse changes in glucose tolerance in patients taking antipsychotic medications.
True
The minimum recommended monitoring for diabetes in patients taking antipsychotic drugs includes only random plasma glucose every 12 months.
The minimum recommended monitoring for diabetes in patients taking antipsychotic drugs includes only random plasma glucose every 12 months.
False
Clozapine and olanzapine carry a minimal risk of developing diabetes compared to other antipsychotic medications.
Clozapine and olanzapine carry a minimal risk of developing diabetes compared to other antipsychotic medications.
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GLP-1 agonists, such as liraglutide, are increasingly being recommended for use in the management of diabetes related to antipsychotic use.
GLP-1 agonists, such as liraglutide, are increasingly being recommended for use in the management of diabetes related to antipsychotic use.
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Schizophrenia is not associated with insulin resistance or diabetes.
Schizophrenia is not associated with insulin resistance or diabetes.
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First-generation antipsychotics have been shown to have no impact on glucose tolerance.
First-generation antipsychotics have been shown to have no impact on glucose tolerance.
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The risk of developing diabetes is higher with clozapine compared to other second-generation antipsychotics.
The risk of developing diabetes is higher with clozapine compared to other second-generation antipsychotics.
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Studies show that all first-generation antipsychotics have the same impact on diabetes incidence.
Studies show that all first-generation antipsychotics have the same impact on diabetes incidence.
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Diabetes linked to clozapine is often associated with obesity.
Diabetes linked to clozapine is often associated with obesity.
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Aripiprazole and ziprasidone are beneficial for individuals with predisposition to diabetes.
Aripiprazole and ziprasidone are beneficial for individuals with predisposition to diabetes.
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The risk of developing diabetes is higher in elderly adults compared to younger adults.
The risk of developing diabetes is higher in elderly adults compared to younger adults.
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Lumateperone is associated with significant effects on glucose parameters.
Lumateperone is associated with significant effects on glucose parameters.
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Formal guidelines for monitoring diabetes are completely unified.
Formal guidelines for monitoring diabetes are completely unified.
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Anomalies in fasting plasma glucose levels should be followed up with an oral glucose tolerance test.
Anomalies in fasting plasma glucose levels should be followed up with an oral glucose tolerance test.
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Olanzapine is likely more diabetogenic than risperidone, associated with lower plasma glucose levels.
Olanzapine is likely more diabetogenic than risperidone, associated with lower plasma glucose levels.
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Quetiapine is linked to new-onset diabetes at doses below 400mg.
Quetiapine is linked to new-onset diabetes at doses below 400mg.
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Impaired glucose tolerance can occur with olanzapine even in the absence of obesity or family history of diabetes.
Impaired glucose tolerance can occur with olanzapine even in the absence of obesity or family history of diabetes.
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Risperidone has a higher frequency of adverse effects compared to clozapine and olanzapine.
Risperidone has a higher frequency of adverse effects compared to clozapine and olanzapine.
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Amisulpride appears to elevate plasma glucose and is associated with a heightened diabetes risk.
Amisulpride appears to elevate plasma glucose and is associated with a heightened diabetes risk.
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Both aripiprazole and ziprasidone have fully discussed data regarding their glucose effects.
Both aripiprazole and ziprasidone have fully discussed data regarding their glucose effects.
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The diabetic risk associated with risperidone is greater in patients who are over 40 years of age.
The diabetic risk associated with risperidone is greater in patients who are over 40 years of age.
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Quetiapine's diabetogenic potential is considered lesser compared to first-generation antipsychotics (FGAs).
Quetiapine's diabetogenic potential is considered lesser compared to first-generation antipsychotics (FGAs).
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Study Notes
Antipsychotics and Diabetes
- Yearly diabetes screening is recommended for all patients on antipsychotics.
- Monitor for symptoms of diabetes (fatigue, Candida infection, thirst, polyuria).
- Switching to antipsychotics with lower cardiometabolic risk (aripiprazole, ziprasidone, lurasidone) may reverse glucose tolerance changes.
- Standard antidiabetic treatments are recommended.
- Pioglitazone may be beneficial but watch for hepatotoxicity.
- GLP-1 agonists (liraglutide) are increasingly used.
Diabetes Risk Levels for Antipsychotics
- High Risk: Clozapine, olanzapine
- Moderate Risk: Quetiapine, risperidone, phenothiazines
- Low Risk: High-potency FGAs (e.g., haloperidol)
- Minimal Risk: Aripiprazole, amisulpride, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, ziprasidone
Antipsychotics and Mechanism of Diabetes
- Schizophrenia is associated with higher insulin resistance and diabetes rates.
- Lifestyle interventions are effective in preventing diabetes.
- Mechanisms for antipsychotic-related diabetes may involve:
- 5HT2/5HT2A antagonism
- Increased plasma lipids
- Weight gain
- Leptin resistance
- Insulin resistance can occur even without weight gain.
First-Generation Antipsychotics (FGAs)
- Phenothiazine derivatives are strongly associated with impaired glucose tolerance and diabetes.
- Aliphatic phenothiazines may be more linked than fluphenazine or haloperidol.
- Some studies suggest no difference between FGAs and SGAs, but others show a slight increase in diabetes with SGAs.
- Other FGAs (e.g., loxapine) are associated with hyperglycemia.
Second-Generation Antipsychotics (SGAs)
- Clozapine is strongly linked to hyperglycemia, impaired glucose tolerance, and diabetic ketoacidosis.
- The risk of diabetes is higher with clozapine than other SGAs or FGAs, especially in younger patients.
- Up to a third of patients might develop diabetes after 5 years of treatment, some within 6 months or later.
- Death from ketoacidosis has been reported.
- Diabetes associated with clozapine is not necessarily linked to obesity.
Olanzapine
- Associated with impaired glucose tolerance, diabetes, and diabetic ketoacidosis.
- Risk may be higher in younger patients.
- May directly induce insulin resistance.
- Impaired glucose tolerance can occur without obesity or family history of diabetes.
- Likely more diabetogenic than risperidone.
Risperidone
- Linked to impaired glucose tolerance, diabetes, and ketoacidosis in case reports.
- Fewer adverse effect reports compared to clozapine or olanzapine.
- Changes in fasting glucose may be less common with risperidone than olanzapine.
- Potential increased risk in patients under 40 years of age.
- Affects fasting glucose and plasma glucose post glucose challenge.
Quetiapine
- Linked to new-onset diabetes and ketoacidosis.
- Fewer reports than with olanzapine or clozapine.
- Appears more likely than FGA medications to be associated with diabetes.
- Risk may be dose-related, with daily doses of 400mg or more linked to HbA1c changes.
- Two studies show quetiapine to be equal to olanzapine in diabetes incidence.
Other SGAs
- Amisulpride does not seem to elevate plasma glucose and is not associated with diabetes.
- Sulpiride has one reported case of ketoacidosis.
- Aripiprazole and Ziprasidone have referenced data, but are not discussed in detail.
Antipsychotic-Related Diabetes: Summary of Effects on Glucose Homeostasis
- Some antipsychotics do not appear to affect glucose homeostasis.
- Aripiprazole, amisulpride, aripiprazole, and ziprasidone are recommended for those with diabetes or a predisposition to diabetes, or as alternatives to other diabetogenic antipsychotics.
- Initial data suggests that lurasidone, asenapine, brexpiprazole, and cariprazine have minimal effects on glucose tolerance.
- Lumateperone appears to have no effect on glucose parameters.
Predicting Antipsychotic-Related Diabetes
- Risk of diabetes is higher in younger adults than the elderly.
- Patients in their first episode of antipsychotic treatment may be especially prone to diabetes.
- Rapid weight gain and elevated plasma triglycerides during treatment might predict future development of diabetes.
Monitoring for Antipsychotic-Related Diabetes
- Diabetes is a growing concern, associated with obesity and certain ethnic groups.
- Diabetes significantly increases cardiovascular mortality.
- Interventions to lower blood sugar and minimize other diabetes risk factors are essential.
- Formal guidelines don't fully agree on monitoring procedures, requiring improvement.
- Urine glucose, random plasma glucose, and oral glucose tolerance tests are encouraged.
- OGTTs are the most sensitive method but can be difficult to perform.
- FPG tests are recommended but less sensitive than OGTT, should be followed up with OGTT if abnormal.
- HbA1c can be used to detect and monitor diabetes; monitoring frequency should consider weight gain and risk factors (e.g., family history of diabetes).
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Description
This quiz covers the relationship between antipsychotic medications and diabetes risk, highlighting the importance of yearly screening for patients on these drugs. It discusses various antipsychotics, their associated diabetes risk levels, and possible management strategies to mitigate these risks.
