Antipsychotics, weight gain, and medication adherence

[valid username]

I have met two different patients with this pattern: quit taking antipsychotics because of the weight gain. They lose weight, go back inpatient, we put them back on olanzapine because they are so skinny. Looking through the charts, the pattern repeats itself.

I'm an m4 trying to match into psych, so I don't get to make decisions yet. Even so, I can see this is probably a fairly common problem.

How do you approach this? No one seems to like to change antipsychotics once we have one working, so do you start with a different one and just trust they monitor and hope for an acceptable amount of weight? Or do you counsel about increasing exercise right from the beginning? Or what?

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[nitemagi]

Start with adding metformin.

 

[uname943]

Work early on getting patient and family buy-in for long acting injectibles. I usually use something more weight neutral than olanzapine.

 

[hamstergang]

I'd switch to something with less weight gain potential unless they've already been tried and failed.

 

[st2205]

How do you approach this? No one seems to like to change antipsychotics once we have one working, so do you start with a different one and just trust they monitor and hope for an acceptable amount of weight? Or do you counsel about increasing exercise right from the beginning? Or what?

None of them work very well when they’re not taken. A little patient autonomy and compromise may go a long way. I haven’t found much utility in trying to convince anyone to take anything unless there’s something really riding on it (such as keeping them out of the hospital I’m thos case). If weight gain leads to enough inadherence to significantly increase likelihood of hospitalization, then that’s a good sign that Zyprexa may not be the best option, regardless of how awesome a psychiatrists thinks they look on it while hospitalized.

On the flip side, that’s not to say that giving them more autonomy will always lead to compliance (or even trend that way).

 

[valid username]

I should clarify, we are talking adherence lasting several months, up to just over a year, at a time. Thanks for the feedback!

 

[valid username]

Work early on getting patient and family buy-in for long acting injectibles. I usually use something more weight neutral than olanzapine.

Ironically, one of these patients requested injectables. Could not get the coverage. Yes, a different can of worms I know.

So, even if the patient is severly underweight, it may be better to start with something other than olanzapine as opposed to start olanzapine then switch when the patient approaches a healthy weight.

 

[birchswing]

Ironically, one of these patients requested injectables. Could not get the coverage. Yes, a different can of worms I know.

So, even if the patient is severly underweight, it may be better to start with something other than olanzapine as opposed to start olanzapine then switch when the patient approaches a healthy weight.

Are you saying doctors purposefully induce insulin resistance and metabolic syndrome to help people gain weight? Why not just increase caloric intake?

 

[FlowRate]

Are you saying doctors purposefully induce insulin resistance and metabolic syndrome to help people gain weight? Why not just increase caloric intake?

You have the arrows backwards. You get insulin resistance, metabolic syndrome, and weight gain by increasing caloric intake (hunger.)

 

[birchswing]

You have the arrows backwards. You get insulin resistance, metabolic syndrome, and weight gain by increasing caloric intake (hunger.)

Atypical antipsychotics cause metabolic changes and can induce insulin resistance even if they don't increase weight, and in the cases where they cause weight gain, the metabolic changes precede weight gain. The person I was responding to said that they were putting patients on Zyprexa purposefully to increase weight. Before the weight increases, the body increases glucose production and becomes less effective at using it. It increases appetite and leads to weight gain, which is probably likely due to the metabolic changes but maybe other factors as well. You can maintain a healthy weight on an atypical and still develop insulin resistance (I've done it—I managed to get a high fasting insulin level in spite of normal weight). So what I was saying is that rather than pick an atypical that has the worst metabolic profile to help someone gain weight, why not pick one with a better metabolic profile and have the patient gain weight through purposefully eating more, not eating more because the body's cells are being starved of glucose through insulin resistance.

 

[valid username]

The person I was responding to said that they were putting patients on Zyprexa purposefully to increase weight.

No, I did not say that I was putting patients on Zyprexa. I have never even put a patient on Zyprexa or anything else. As I said in my post, I am an m4 trying to match into psychiatry. I am just trying to understand and learn from the cases I am exposed to for future reference. In my limited experience, I have noticed that I learn a lot when I study things about my patients that I don't fully understand. Obviously, I would not ask my attending to justify her choice of antipsychotic to me. I am simply trying to learn from the experience.

I did research the issue independently before asking the question here, but I think I didn't research it thoroughly enough. I apologize, I will go back and read more about the mechanism(s) behind the weight gain and try again to figure out how I may approach this issue if I encounter it in the future.

To answer your other question: why not just increase the caloric intake instead of using the antipsychotic? For 1 pt, there were delusions of poisoned food that resolved within days of reintroducing zyprexa. There was a similar presentation/response originally. This patient definitely needs an antipsychotic.

 

[splik]

Obviously, I would not ask my attending to justify her choice of antipsychotic to me. I am simply trying to learn from the experience.

unless your attending is an idiot (which there is a good chance she is) you should feel free as a student to ask your attending about this. the key is to be respectful and ask for your own learning (playing dumb is also a good way to be non-threatening/confrontational about it). I expect and actively encourage my students and residents to ask "so i'm wondering is there a particular reason that you thing this drug is best?" Because different psychiatrists do wildly different things the only way you're going to figure out what is reasonable is by asking people to explain (rather than justify) their reasoning. if they cant provide you a good enough explanation well then you will know that. remember good psychiatrists exist in spite of their training not because of it. take what you can and try not to pick up too many bad habits.

 

[hamstergang]

Atypical antipsychotics cause metabolic changes and can induce insulin resistance even if they don't increase weight, and in the cases where they cause weight gain, the metabolic changes precede weight gain. The person I was responding to said that they were putting patients on Zyprexa purposefully to increase weight. Before the weight increases, the body increases glucose production and becomes less effective at using it. It increases appetite and leads to weight gain, which is probably likely due to the metabolic changes but maybe other factors as well. You can maintain a healthy weight on an atypical and still develop insulin resistance (I've done it—I managed to get a high fasting insulin level in spite of normal weight). So what I was saying is that rather than pick an atypical that has the worst metabolic profile to help someone gain weight, why not pick one with a better metabolic profile and have the patient gain weight through purposefully eating more, not eating more because the body's cells are being starved of glucose through insulin resistance.

For people with certain delusions or anorexia, telling them to just eat more doesn't work. In addition there are plenty of people who want to gain weight and try to eat a lot but simply can't get the results.

Regardless, Zyprexa wouldn't be used simply to cause weight gain. We have other meds that don't hit as many receptors that are known to increase appetite.

Also, many patients gain weight on Zyprexa without evidence of significant metabolic effects (blood sugar and cholesterol don't change from baseline).

 

[SeniorWrangler]

I thought olanzapine had a relatively good adherence rate due to its lack of dystonic reactions, but antipsychotics in general have really poor adherence. Also, people don't usually just lose the weight after they stop olanzapine, they have to work at it like any other weight loss.