Atypical antipsychotics & weight gain-questions

[whopper]

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CATIE did a great job of ranking weight gain between the atypicals.

But an attending I saw at a lecture posed the following (paid by Lily)....
According to him-some patients do not gain weight with olanzapine (yeah, true), and olanzapine did very well on the CATIE trial (true despite that they often were given more than the manufacturer's reccomended dose).

He then mentioned how weight gain in olanzapine occurs usually within the first few weeks of treatment (ok didn't know that but I'm finding some articles that back this up).

So he argued---
if the weight gain occurs within the first few weeks of treatment, and its highly efficacious
1) give olanzapine & weigh patients & have lipid panel testing before they start using it
2) provide another appointment within 3-4 weeks
3) if no weight gain occurs by 3-4 weeks patients will by highly unlikely to be in the weight gainer category


OK-very convincing argument. Problem is his study was done by Lily. I did a pubmed check for any similar data from a 3rd party researcher. There were so many hits--and it was too much information to go through.

Anyone know of any studies that could back this claim or at least provide data that would cover this area?

 

[Anasazi23]

CATIE did a great job of ranking weight gain between the atypicals.

But an attending I saw at a lecture posed the following (paid by Lily)....
According to him-some patients do not gain weight with olanzapine (yeah, true), and olanzapine did very well on the CATIE trial (true despite that they often were given more than the manufacturer's reccomended dose).

He then mentioned how weight gain in olanzapine occurs usually within the first few weeks of treatment (ok didn't know that but I'm finding some articles that back this up).

So he argued---
if the weight gain occurs within the first few weeks of treatment, and its highly efficacious
1) give olanzapine & weigh patients & have lipid panel testing before they start using it
2) provide another appointment within 3-4 weeks
3) if no weight gain occurs by 3-4 weeks patients will by highly unlikely to be in the weight gainer category


OK-very convincing argument. Problem is his study was done by Lily. I did a pubmed check for any similar data from a 3rd party researcher. There were so many hits--and it was too much information to go through.

Anyone know of any studies that could back this claim or at least provide data that would cover this area?

I don't know studies off the top of my head, but i do know that this is the Lily mantra nowadays. There was a study published in the British Journal of Psychiatry that looked at this. It seemed to me from just a brief perusal that weight gain started to level at around week 30.

This is going to be slightly off topic, but I just have to say that the more studies I read, the more researchers I know doing actual clinical research, the more I distrust clinical trials and studies in general. The patients I see in my office are often so far different than the patients eligible for these studies, that I seriously wonder about the generalizability to "real world psychiatry" in any of them. This rings especially true when I know through clinical experience that A works, or that B combination does not work, and studies refute to the contrary. I feel that if I practiced psychiatry based only on treatment algorithms and treatment guidelines, I'd be a much worse psychiatrist. (i.e. polypharmacy has no place in psychiatry, anyone?)

 

[Therapist4Chnge]

He then mentioned how weight gain in olanzapine occurs usually within the first few weeks of treatment (ok didn't know that but I'm finding some articles that back this up).

So he argued---
if the weight gain occurs within the first few weeks of treatment, and its highly efficacious
1) give olanzapine & weigh patients & have lipid panel testing before they start using it
2) provide another appointment within 3-4 weeks
3) if no weight gain occurs by 3-4 weeks patients will by highly unlikely to be in the weight gainer category

I read this awhile back, though other studies and anecdotal cases (I think what 'Sazi says is true about the 'research population' not being as reflective as the 'general population') significant weight gain has been shown, much more than some of the other atypical options.

Whenever I read a pharma-sponsored study I definitely pick it over thoroughly. The methods are sometimes screwy and/or dosing can vary from what you'd see in a real setting (I read a study last week comparing various anti-depressants, and they barely touched the low-end of the average therapeutic dose, so when they used 'their' medication...it came out looking better). In the end all studies should be reviewed closely. Pharma research in particular is tough because of the low N's that tend to happen. There are some pre and post-hoc adjustments that can be done, but they are far from ideal.

 

[whopper]

Definitely agree with the above. That's why I want to double check any 3rd party sources before I take what was said at face value.

I have spent over an hour perusing through pubmed and there's so many hits its bringing up too many articles on weight gain & olanzapine but no articles that'll back up this 3,4,5 rule that was mentioned.

The speaker was a highly respected professor of psychiatry, and of course pharm companies can have hell to pay if they give out inaccurate data--> they did give out that data in printed form. However of course as you both mentioned, any doctor has to seriously double check data from a pharm company. They have a conflict of interest; they want profits.

I am though very interested and want to find any data that'll back up the comments. The atypicals we have aren't very effective and olanzapine did do well on CATIE (yeah I know there were some problems here & there). In some patients for example, olanzapine is a good option, e.g. if clozapine was working on the patient but they could not tolerate the side effects, in which case olanzapine (often times mixed with another atypical or typical) is usually the next best med to try.

And it would be nice if a doc could prescribe it, and be able to predict if the weight gain would happen by the time the pt gained 4-5 lbs as opposed to 50.

I did find some very interesting tidbits during my lit reviews---
1) Zyprexa Zydis has very little weight gain compared to regular olanzapine. Why this is? The articles did not have an answer. Problem though is Zydis is very very expensive.
2) In animal studies, olanzapine mixed with melatonin did not have animals suffering from weight gain (animal studies show weight gain with olanzapine use). Not saying this would work in humans, but it is worth studying.
3) there are studies in the works to see if a specific medication can cancel the weight gain effect of olanzapine.--topamax & glucophage were some I saw. Results still pending.

As of now I will still prescribe the same way I'm doing it. If I do put a pt on olanzapine, I will see if this 3,4,5 rule pans out, but I will not put a patient on it that I otherwise wouldn't have done before I heard about it--unless I see 3rd party studies that back it up.

I just have to say that the more studies I read, the more researchers I know doing actual clinical research, the more I distrust clinical trials and studies in general. The patients I see in my office are often so far different than the patients eligible for these studies,

I sat through a great lecture about this very topic.
Psychiatry research studies need to follow precise models & for that reason have specific inclusion & exclusion criteria. E.g. a patient to be included in the study needed to have an exact DSM-IV dx of the disease.

Sounds good? Well yeah, on paper. Several patients as we know do not follow an exact DSM criteria.
Add to that that several studies don't want to include patients that do not score the way the researchers want them to score on rating scales (which themselves have problems but most clinicians I've seen don't actually critically evaluate the rating scales, nor use them much), don't include patients that would not follow up with outpatient appointments, do not include patients with comorbid conditions, yada yada yada...

And what you end up with is a perfect model patient who ends up being the type of patient for the study.

Yes, this type of patient is the best patient for a study, but as we know, most of our patients aren't like this in real life.

I had this one patient, and 4 out of 4 doctors who had her for over a year agreed--the biggest indicator that she was truly recovering from her psychosis was her hair. When she was getting better & her cognition returned, she fixed her hair very well. When she was sick & to the point where she lost her insight, she fixed it up in a beehive manner. Her insight actually matched that hair quite well. No scale is going to be able to track a unique trait like that in the population of schizophrenics.

 

[Anasazi23]

I had this one patient, and 4 out of 4 doctors who had her for over a year agreed--the biggest indicator that she was truly recovering from her psychosis was her hair. When she was getting better & her cognition returned, she fixed her hair very well. When she was sick & to the point where she lost her insight, she fixed it up in a beehive manner. Her insight actually matched that hair quite well. No scale is going to be able to track a unique trait like that in the population of schizophrenics.

You'd be surprised. Check out the H.A.I.R. (Hairstyle Assessment Indicator of Relapse) project.