Adding Metformin to VPA to control weight gain?

[shahseh22]

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I have a moderately obese gentleman with Schizoaffective disorder and Meth use history who is still having a lot of AH and mood instability on VPA 1,000 mg, Risperdal 8 mg, Trazodone 150 mg and Wellbutrin 150 mg BID (has been snorting at group home a few times). His BMI is 37 and he wants to switch to Zyprexa as it worked for him in the past. I told him I would need labs before making any changes. But if I decide to cross-taper to Zyprexa, will adding the Metformin also help with the weight he has gained from VPA (I'm assuming this one is the biggest instigator to his weight gain)?

I don't know how severe his symptoms are but he says the AH and mood instability is causing him to be suicidal. His therapist is also worried too.

Gosh I miss working with kids.

Thanks for any tips or reading material you can give me.

 

[wolfvgang22]

Unlikely. I wouldn't consider metformin unless I could reduce overall polypharmacy first. Depakote probably is the main issue with weight gain. Also, Risperidone can cause significant weight gain, too. Have you tried lowering the dosage on these slowly and see how he does? Does he really need 8mg of Risperidone? You probably get diminishing returns after 4mg. Consider antipsychotics that cause less weight gain. I have good results with abilify in several such patients. Even quetiapine causes less weight gain than Zyprexa, Risperidone, and Depakote. Is Depakote necessary? If so, is lithium something you have considered instead?
If you can use a more serotonergic antipsychotic or lithium you probably won't need the bupropion.

 

[robellis]

Unlikely. I wouldn't consider metformin unless I could reduce overall polypharmacy first. Depakote probably is the main issue with weight gain. Also, Risperidone can cause significant weight gain, too. Have you tried lowering the dosage on these slowly and see how he does? Does he really need 8mg of Risperidone? You probably get diminishing returns after 4mg. Consider antipsychotics that cause less weight gain. I have good results with abilify in several such patients. Even quetiapine causes less weight gain than Zyprexa, Risperidone, and Depakote. Is Depakote necessary? If so, is lithium something you have considered instead?
If you can use a more serotonergic antipsychotic or lithium you probably won't need the bupropion.

im not sure about the idea that seroquel causes less weight gain than risperdal..

 

[clausewitz2]

im not sure about the idea that seroquel causes less weight gain than risperdal..

I hope what he means is that seroquel by its lonesome is not as bad for weight gain as VPA + risperidone +olanzapine. Otherwise he may have temporarily taken leave of his senses.

Geodon or lurasidone would be good options here. He has obviously trialled enough antipsychotics to get through prior auth.

Also, why is clozapine not in the mix? There is a very good chance he could make do with clozapine by itself (which, admittedly, causes weight gain) instead of three other agents that cause weight gain.

BMI of >37 I would seriously consider using wellbutrin (or even wellbutrin + naltrexone) just for weight loss, but metformin is the most robustly supported pharmacological intervention here for neuroleptic-associated weight gain. Five gets you ten he is prediabetic or about to be regardless. I feel like we as a specialty could do with becoming generally more comfortable with tackling weight loss for seriously obese patients given how often we make people seriously obese.

 

[NickNaylor]

I think utilizing metformin for weight gain prophylaxis when using antipsychotics is a pretty solid idea, and barring any contraindications I will usually do so in patients that are started on a highly metabolically active antipsychotic and/or have comorbid medical conditions.

As far as weight gain with risperidone vs. quetiapine, I was initially a bit skeptical but... the truth shall set ye free: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998960/pdf/pone.0094112.pdf (figures 2-7)

 

[Merovinge]

I think utilizing metformin for weight gain prophylaxis when using antipsychotics is a pretty solid idea, and barring any contraindications I will usually do so in patients that are started on a highly metabolically active antipsychotic and/or have comorbid medical conditions.

As far as weight gain with risperidone vs. quetiapine, I was initially a bit skeptical but... the truth shall set ye free: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998960/pdf/pone.0094112.pdf (figures 2-7)

For those reading at home keep in mind that metabolic impacts of atypicals in children is somehow vastly different than in adults (if anyone knows why this is, I'd love to hear it). Abilify is associated with significant weight gain in children (much to my chagrin, as it can be a lifesaving medication in the ASD/ID population).

 

[wolfvgang22]

For those reading at home keep in mind that metabolic impacts of atypicals in children is somehow vastly different than in adults (if anyone knows why this is, I'd love to hear it). Abilify is associated with significant weight gain in children (much to my chagrin, as it can be a lifesaving medication in the ASD/ID population).

True. Risperidone seems to cause weight gain more often in kids compared to adults, also for unknown reasons. Anyway, the patient in question here is an adult.
The good news is there seems to be a several options for this patient, barring other information such as other past medication trials, allergies, other medications, etc.

I don't think metformin is a bad idea at all, but my intuition tells me this patient could be over-medicated by previous prescribers with Depakote and Risperidone and other medications with less metabolic effects might provide better symptom control with less weight gain. But, I've been wrong before.

I advocate stopping or reducing the medications causing the weight gain in favor of a different med if possible before adding adjunctive meds like metformin, in order to limit polypharmacy. That's just my general approach.

 

[thepoopologist]

I have a moderately obese gentleman with Schizoaffective disorder and Meth use history who is still having a lot of AH and mood instability on VPA 1,000 mg, Risperdal 8 mg, Trazodone 150 mg and Wellbutrin 150 mg BID (has been snorting at group home a few times). His BMI is 37 and he wants to switch to Zyprexa as it worked for him in the past. I told him I would need labs before making any changes. But if I decide to cross-taper to Zyprexa, will adding the Metformin also help with the weight he has gained from VPA (I'm assuming this one is the biggest instigator to his weight gain)?

I don't know how severe his symptoms are but he says the AH and mood instability is causing him to be suicidal. His therapist is also worried too.

Gosh I miss working with kids.

Thanks for any tips or reading material you can give me.

I guess the first question is why he's still symptomatic. And I agree with the comments about consolidation.

What's his VPA level at 1000 mg? You could go up on the dose, or you could switch him to Lithium due to the suicidality and due to the fact that maybe VPA is contributing to the weight gain and maybe you're anticipating adding Zyprexa and want to limit/balance metabolic risk. Obviously this goes out the window if he likes to overdose on pills.

I wouldn't switch Risperdal with Zyprexa if he's still hallucinating. That is a robust dose of Risperdal and if he's wanting Zyprexa then the options would be to increase the Risperdal by itself or keeping Risperdal as is and adding the Zyprexa and starting the metformin. Switching to Clozaril is also an idea, but a lot of people hate the blood draws and slower titration is usually done to keep things tolerable

Wellbutrin seems like a detriment especially since he's snorting it and I have no idea how it's beneficial in the context of mood instability. It's probably fairly activating for him given his dose and chose route of administration. If you want to go the conservative route, your first step could be to get rid of this first while you up the mood stabilizer.

Is Trazadone for sleep? If you were to increase the mood stabilizer and/or antipsychotic could you get rid of it?

I would add that the timing of each change would depend on the severity of symptoms

 

[Candidate2017]

I don't know how severe his symptoms are but he says the AH and mood instability is causing him to be suicidal. His therapist is also worried too.

Gosh I miss working with kids.

Setting aside metabolic effects, why jump on meds when you haven't conceptualized the severity of his symptoms?

How did he get a schizoaffective dx? Did you diagnose it or is it a garbage dx someone gave them for inpatient billing purposes years ago? What exactly is this mood "instability"? What are the specifics of his AH? How reliable is his self-report? What does the group home report? Why does he require a group home? What is his intellectual functioning? UDS results? Etc, etc.

Of course his therapist is worried. Pretty much every non-PhD "therapist" take self reported symptoms at face value and love to suggest meds to the patient and psychiatrist. Are they even working with him on his addiction? The group home worker who hangs out with him 8-10 hrs a day is a more reliable source of info. But probably not much more reliable if he is able to stash and snort his Wellbutrin.

Second, given this patient needs to be in a group home and has an addiction issue, I would suggest this patient is closer to the child spectrum than adult.

 

[Attending1985]

Of course his therapist is worried. Pretty much every non-PhD "therapist" take self reported symptoms at face value and love to suggest meds to the patient and psychiatrist. Are they even working with him on his addiction? The group home worker who hangs out with him 8-10 hrs a day is a more reliable source of info. But probably not much more reliable if he is able to stash and snort his

THIS! Most frustrating thing about practicing

 

[calvnandhobbs68]

Setting aside metabolic effects, why jump on meds when you haven't conceptualized the severity of his symptoms?

How did he get a schizoaffective dx? Did you diagnose it or is it a garbage dx someone gave them for inpatient billing purposes years ago? What exactly is this mood "instability"? What are the specifics of his AH? How reliable is his self-report? What does the group home report? Why does he require a group home? What is his intellectual functioning? UDS results? Etc, etc.

Yup.

If this dude can fake the group home out by stashing and snorting his Wellbutrin and has a hx of meth use, you sure he's not sneaking meth in too?

Agree with the why is this guy in a group home and getting info from them. Unless he's pretty severely psychotic/low functioning, schizoaffective disorder and substance use doesn't always land you in a group home unless he's there for drug treatment too? There's plenty of psychotic homeless guys who aren't getting vouchers for a group home from uncle sam, so what landed him in there?

 

[Stagg737]

I think utilizing metformin for weight gain prophylaxis when using antipsychotics is a pretty solid idea, and barring any contraindications I will usually do so in patients that are started on a highly metabolically active antipsychotic and/or have comorbid medical conditions.

As far as weight gain with risperidone vs. quetiapine, I was initially a bit skeptical but... the truth shall set ye free: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998960/pdf/pone.0094112.pdf (figures 2-7)

I found this quite interesting given that Quetiapine is typically seen as worse in terms of weight gain than Risperidone. Even more interesting is that the data seems to be suggesting that Risperidone has a higher rate of ongoing weight gain after 38 weeks than Quetiapine does, which goes directly against everything I've seen previously both clinically and in literature. Like Merovinge brought up, I'd be curious to know how much of this could be due to a difference in the use of these in children and those with ASD/ID, as I've seem Risperdal prescribed for these individuals fairly frequently but rarely see Quetiapine in those populations (often d/t the metabolic concerns).

 

[shahseh22]

thanks for all the useful info. He is in a sober living home actually. Gosh I don't know what kind of treatment these folks are getting. Also, yes, i work in a setting where anyone who is "hearing voices" gets labeled Schizo-something.

If one is on VPA or even Prozac, is it ok to give Metformin for weight gain?

 

[the5thelement]

What about switching from Valproate to Topiramate?

 

[hamstergang]

What about switching from Valproate to Topiramate?

Is there any evidence that Topiramate works as a mood stabilizer?

 

[the5thelement]

Is there any evidence that Topiramate works as a mood stabilizer?

Many published articles have shown some efficacy in a wide range of disorders, including bipolar disorder, PTSD,
alcohol dependence, binge-eating disorder, and obesity.

Open-label adjunctive topiramate in the treatment of bipolar disorders

Background: To preliminarily explore the spectrum of effectiveness and tolerability of the new antiepileptic drug topiramate in bipolar disorder, we e…

www.sciencedirect.com

 

[calvnandhobbs68]

Many published articles have shown some efficacy in a wide range of disorders, including bipolar disorder, PTSD,
alcohol dependence, binge-eating disorder, and obesity.

Open-label adjunctive topiramate in the treatment of bipolar disorders

Background: To preliminarily explore the spectrum of effectiveness and tolerability of the new antiepileptic drug topiramate in bipolar disorder, we e…

www.sciencedirect.com

I mean a 50 patient open label trial isn’t the most convincing evidence in the world.

There’s definitely more evidence for Depakote than topiramate. But that’s assuming this patient needs a mood stabilizer to begin with and didn’t get diagnosed with schizoaffective disorder bc he was high on meth.

 

[whopper]

IMHO doctors should be more open to providing Metformin. It has benefits in reducing glycosylation damage related to excessive eating.
With weight gain I do see some improvement in patients but like any med it doesn't work all the time or even close to it, but is a preferable alternative to simply dispensing a controlled substance such as a stimulant. I hardly ever give stimulants out for weight gain, I believe in my entire career I only did it if less than 5x but I see that several physicians give it out liberally, without warning patients of their addictive potential and not trying non-controlled substances first such as Metformin, Naltrexone or Bupropion. Add to this any doctor should tell patients to utilize diet and exercise as the main tool.