Be careful in treating obesity in schizophrenics

[michaelrack]

"Mississippi State Board of Medical Licensure – Administrative Code
Any off-label use of any medication that does not have Food and Drug Administration approval for use in the treatment of weight loss is prohibited. Thyroid hormone, diuretics, vitamin B12, B1, B2, B6, methionine, choline, inositol, chromium picolate and human chorionic gonadotropin are examples of medications that may not be used in the sole treatment of weight loss and are not inclusive examples. Off-label use of medication that does not have Food and Drug Administration approval for the sole use and treatment of weight loss is prohibited in individual practice or allowing off-label use by midlevel providers will result in discipline by the Board. (Non FDA approved supplements may be used in the overall treatment of weight loss.)"

In my state, using metformin or an H2 blocker (not a very well validated strategy) solely to counteract antipsychotic associated weight gain is presumably prohibited. Anyone else have rules/laws like this in their state?

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[hamstergang]

Why does Mississippi do this? Seems bad.

 

[notdeadyet]

Can you run labs that show support for a diagnosis of a metabolic syndrome and rx metformin for that on-label use? It's not as good as prophylactically, but it beats watching patients swell up from antipsychotic-associated weight gain.

No such laws out here in California. I'm pushing my program into using metformin for antipsychotic weight gain.

 

[OldPsychDoc]

Why does Mississippi do this? Seems bad.

I would imagine that it was a reaction against people setting themselves up as alternative weight loss clinics?
Overkill, though.

 

[birchswing]

I've come across a resistance to prescribe metformin personally, and didn't understand it. It seems very safe. My doctor was concerned about it making me gassy in spite of me telling him I wouldn't mind that—I'm not saying that as a joke, what's a little extra gas?

 

[MLT2MT2DO]

Why does Mississippi do this? Seems bad.

http://health.usnews.com/health-news/articles/2012/08/16/most-and-least-obese-us-states

Seems simple enough to me, they were feeling the heat from Louisiana and needed to put a little more distance between them.

 

[notdeadyet]

Excellent, MLT.

I'm a little troubled by the link, that indicates that you can have 1 out of 5 people in your state be obese and still be the least obese state in the country. Wow...

 

[michaelrack]

I would imagine that it was a reaction against people setting themselves up as alternative weight loss clinics?
Overkill, though.

Exactly. MS also has strict regulations for using FDA-approved obesity meds, including monthly visits.

MS also has problems with "Low T" clinics and doc's/NP giving "lipo" injections as well as B12 injections for no good indication.

 

[michaelrack]

Can you run labs that show support for a diagnosis of a metabolic syndrome and rx metformin for that on-label use? It's not as good as prophylactically, but it beats watching patients swell up from antipsychotic-associated weight gain.

.

I think that would be ok, especially if you documented some type of lipid abnormality that you were treating.

 

[AnnTaylor]

Topamax seems to get added on in my hood without eyebrows going up.

 

[eaglepsych]

how much weight (percentage or pounds) do patients in your experience typically lose when metformin is added to an SGA? I definitely believe it can be helpful, but haven't used it nearly enough to know what to expect when using it (if anyone can weigh in on how often this helps also that would be great). thx!

 

[notdeadyet]

how much weight (percentage or pounds) do patients in your experience typically lose when metformin is added to an SGA? I definitely believe it can be helpful, but haven't used it nearly enough to know what to expect when using it (if anyone can weigh in on how often this helps also that would be great). thx!

I read a study that was done recently that gave metformin to folks who had gained 7% body weight after starting atypical antipsychotics. Patients had lost about 5% of body weight at week 12. I don't have the source handy but it's in a 2012 article in Schizophrenia Research.

 

[eaglepsych]

thank you. just found this study in the green journal that seems pretty legit from the abstract...

http://www.medscape.com/viewarticle/809505

seems like when diet and exercise were provided to both groups, pt's lost 4.5 more lbs in a 4 month study than pt's receiving placebo. will be most interested in longer term studies (4.5 lbs isn't much in someone who weighs say 300 lbs, but 12 lbs in a year or 24 lbs in 2 years surely would).

 

[notdeadyet]

I'd also look at studies that compare metformin to placebo without the diet/exercise component. For many populations, adhering to a diet and exercise regimen is not going to happen and seeing metformins effect in that situation is instructive.

This isn't meant to be a slam on our schizophrenic patients. Heck, most of a PMD's census will not adhere to a diet and exercise regimen...


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[vistaril]

Exactly. MS also has strict regulations for using FDA-approved obesity meds, including monthly visits.

MS also has problems with "Low T" clinics and doc's/NP giving "lipo" injections as well as B12 injections for no good indication.

A common thing I see is to give something like a magic potion the patient drinks, a b12 shot, and then an rx for phentermine sold at inhouse pharmacy(cheap med with decent profit margin even at a reasonable price)......the phentermine is somewhat effective, and the other stuff is smoke and mirrors and a reason why the patient should pay to be treated at this speciality clinic.

 

[shan564]

I think that these rules are relying on the assumption that you're using medications to treat pure primary obesity... i.e. people who gained weight from fried chicken and sedentary lifestyle. Antipsychotic-induced obesity is a different illness, with a different etiology. You're not using metformin as a pure weight-loss drug, you're using it to prevent side effects from the antipsychotic. Just like using opioids to treat genuine pain.

FWIW, I just met a patient who gained 40 lbs in a year on Seroquel, then lost 7 lbs in a month after starting metformin despite not making any changes to his habits. It's just an n=1, but it was encouraging. I didn't start the metformin - his PCP started it because he developed diabetes - and I realize that this isn't even level 5 evidence, but it's nice to see it actually work.

I don't care if Missouri passes the same "administrative code" cited in the OP - I'm still prescribing metformin. The evidence is there, so if somebody questions the use, I'm pretty sure I can defend it. You don't even have to write "weight gain" as the indication - you could call it prophylaxis against metabolic syndrome in a high-risk patient.

It's clear that the purpose of this rule is to prevent people from prescribing thyroid hormone or Lasix for people who want to lose weight without diet/exercise. I think it'd be silly for them to enforce anything different. If you're really concerned about negative consequences from prescribing metformin for patients on antipsychotics, I'd write a letter to the medical board to let them know that their rule is concerning for providers wanting to prescribe a drug for weight loss in patients who are gaining weight secondary to a genuine medical condition and/or necessary drug treatment, and that they should clarify the rule to avoid compromising patient care.

 

[Fenster]

I think that these rules are relying on the assumption that you're using medications to treat pure primary obesity... i.e. people who gained weight from fried chicken and sedentary lifestyle. Antipsychotic-induced obesity is a different illness, with a different etiology.

Just to play the devil's advocate here, may I ask what the different etiology is? Do antipsychotics cause obesity without causing increased appetite or food intake?

I don't care if Missouri passes the same "administrative code" cited in the OP - I'm still prescribing metformin. The evidence is there...

I'd do the same.

 

[shan564]

Just to play the devil's advocate here, may I ask what the different etiology is? Do antipsychotics cause obesity without causing increased appetite or food intake?

http://www.ncbi.nlm.nih.gov/pubmed/21664918

Also, even if the above article is wrong about peripheral metabolism, I'd still say that the etiology is different because it's intrinsic increase in food intake vs. pharmacologically-induced increase in food intake.

 

[SuperSoccer19]

I find some irony in this subject considering the AHD/ACC/TOS just released a new clinical guideline for obesity management that suggests physicians are not treating it aggressively enough. Nothing overly insightful in the guidelines that most of us probably did not already know, but a few sources introducing the guidelines suggest that insurances might be more likely to pay for nutritional counseling (something I find rarely works in schizophrenics) and bariatric surgeries as long as BMI is over 40 (somehow I thought this was already the norm, but guess not?).

Even though I am an advocate for bariatric surgery in the appropriate population, I think I would sooner use a trial of an off-lable medication if a good one existed prior to making this referral. I also would question whether someone with schizophrenia--where medication compliance by itself and be challenging and where cognitive problems are ubiqitous--might have difficulty being compliant with the post-op diet.

The guideline does not seem to address medication use, but with how many diet pills have been marketed--both prescription and OTC--and then removed from the market due to safety concerns, I think I would rather chance a kidney stone with topamax or lactic acidosis with Metformin.

 

[billypilgrim37]

Just to play the devil's advocate here, may I ask what the different etiology is? Do antipsychotics cause obesity without causing increased appetite or food intake?

They cause obesity in addition to increasing appetite or food intake, just as they alter lipid metabolism and insulin resistance independent of weight gain.

 

[billypilgrim37]

Silly double post.

 

[michaelrack]

I think that these rules are relying on the assumption that you're using medications to treat pure primary obesity... i.e. people who gained weight from fried chicken and sedentary lifestyle. Antipsychotic-induced obesity is a different illness, with a different etiology. You're not using metformin as a pure weight-loss drug, you're using it to prevent side effects from the antipsychotic. Just like using opioids to treat genuine pain.

FWIW, I just met a patient who gained 40 lbs in a year on Seroquel, then lost 7 lbs in a month after starting metformin despite not making any changes to his habits. It's just an n=1, but it was encouraging. I didn't start the metformin - his PCP started it because he developed diabetes - and I realize that this isn't even level 5 evidence, but it's nice to see it actually work.

I don't care if Missouri passes the same "administrative code" cited in the OP - I'm still prescribing metformin. The evidence is there, so if somebody questions the use, I'm pretty sure I can defend it. You don't even have to write "weight gain" as the indication - you could call it prophylaxis against metabolic syndrome in a high-risk patient.

It's clear that the purpose of this rule is to prevent people from prescribing thyroid hormone or Lasix for people who want to lose weight without diet/exercise. I think it'd be silly for them to enforce anything different. If you're really concerned about negative consequences from prescribing metformin for patients on antipsychotics, I'd write a letter to the medical board to let them know that their rule is concerning for providers wanting to prescribe a drug for weight loss in patients who are gaining weight secondary to a genuine medical condition and/or necessary drug treatment, and that they should clarify the rule to avoid compromising patient care.

I don't practice much psychiatry anymore, so this regulation doesn't affect me as a doc too much. But my philosophy now is not to fight the government (feds, state of MS, Medicare regs, med board of MS rules, etc). If there is some collateral damage in war against pill mills, weight loss centers, hydrocodone use etc- well the people get the government they vote for and deserve. I just follow the rules.