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Metformin and Metabolic Side Effects

Discussion in 'Psychiatry' started by AD04, Nov 14, 2017.

  1. AD04

    AD04 5+ Year Member

    Dec 27, 2011
    I have not met one attending who prescribes metformin to combat metabolic side effects of our medications.

    1. Why isn't it done more often?

    2,. If you prescribe metformin, what dose and frequency do you prescribe?

    The articles I've read have varied from 500mg - 2500mg per day.
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  3. hamstergang

    hamstergang may or may not contain hamsters 5+ Year Member

    May 6, 2012
    I'm not used to starting it. Also, the studies suggest a very modest effect overall, so it's not really a wonderful tool.

    I have suggested it a few times but only used it once so far.
  4. PistolPete

    PistolPete Physician 10+ Year Member

    Jul 16, 2006
    I've never used it myself either. Mostly because I wasn't trained that way in residency. But more so because I try and limit the number of medications I prescribe as much as possible, and I'm just not aware of how big of a benefit metformin really provides in combating metabolic side effects. I guess I need to read up on this more.
  5. Coupd'Cat

    Coupd'Cat Caught in Life's Washcycle

    Sep 17, 2017
    An (young-ish) attending I had this past year does. Perhaps it's trickling down.
  6. st2205

    st2205 Attending 10+ Year Member

    Oct 28, 2006
    If I start Zyprexa on someone antipsychotic naive, I’ll start it half the time. Last I reviewed, data is best for weight gain prevention rather than weight loss, so I’ll typically put it on for the first few months and then take it off. However, when I typically start someone on Zyprexa from the get-go, it’s usually because they’re manic in the hospital, so I transition them to something else later, so I typically have a fairly temporary approach to this. No data on that, just clarifying personal preference.
    AD04 likes this.
  7. MedMan80


    May 23, 2017
    Currently the MOBILITY trial is looking at combining metformin with AAP, should be interesting to see the outcome. Check out
  8. NickNaylor

    NickNaylor Thank You for Smoking Physician Lifetime Donor Classifieds Approved 7+ Year Member

    May 22, 2008
    Deep in the heart of Texas
    We had a grand rounds on this topic recently, done by one of the endocrinology faculty to discuss management of metabolic side effects from psychotropics. He mentioned this specifically and did recommend it. His recommendation was to start at 500 mg BID and titrate to 1000 mg BID as tolerated while monitoring renal function and looking out for acidosis.
    Jules A, AD04 and clausewitz2 like this.
  9. Metformin should generally be 1,000mg BID. Any more than that provides minimal/no benefit but with increased diarrhea/gi side effects. Any less than that provides significantly less benefit. All patients, even those with prediabetes, get titrated up to 2g/day by up-to-date internists and endocrinologists. I think starting at 500mg every morning, and then increasing by 500mg every 2-weeks is probably pretty good.

    Overall, it is pretty harmless drug, and you do get a significant A1c benefit from it.

    You have to have an eGFR >30-40 to be on it, per guidelines due to risk of so-called lactic acidosis, but this is probably a myth.
    Jules A, thoffen and AD04 like this.
  10. Liquid8

    Liquid8 2+ Year Member

    Dec 12, 2015

    Attached Files:

  11. bonedrone14

    bonedrone14 2+ Year Member

    Oct 11, 2014
    Thanks for posting the article! I stumbled across this yesterday...anyone with more knowledge than myself have any thoughts? It's definitely an interesting take, and I have some questions that the article left unanswered. I haven't bothered to chase down the actual paper from the study, so I'm left wondering exactly what confounders they controlled for, etc. Anyway, just thought it was interesting in light of this thread.

    Medscape: Medscape Access

    TLDR: austrian study showed that metformin users had a higher incidence of parkinsons and alzheimers
  12. Information Underload

    Information Underload 2+ Year Member

    Aug 4, 2014
    I use it more than I would like to in my child and adolescent population. Many of these kids are more susceptible to weight gain than what would be the case for more traditionally weight-neutral medications in adults, including Abilify, Latuda and Geodon. I find metformin has at least modest effect in reducing some of the weight gain and at times helping with weight loss. Thing is, many of these kiddos with disruptive mood dysregulation disorder and autism really need to be on atypicals to function. I typically don't start metformin with most antipsychotics because parents are squeamish enough about medications and also given that some seem to have zero metabolic sides whatesoever, anyway.

    For kids, depending on their age and size, I gradually titrate to 250mg BID to 500mg BID. For adolescents, I often end up going to 750mg BID over time, as 500mg BID doesn't seem to frequently cut it. Sometimes you have to cut the dosages in half or divide doses throughout the day due to nausea.

    Of note, kids and adults typically see an improvement in their lipid profile when taking metformin. When it comes down to it, I'd rather see them on metformin than a statin.
    AD04 likes this.
  13. Evidence Based

    Evidence Based MS-4 7+ Year Member

    Nov 6, 2009
  14. PistolPete

    PistolPete Physician 10+ Year Member

    Jul 16, 2006
    What percentage of your DMDD kids are on atypicals? Are most of them on atypical antipsychotic monotherapy? I usually try an ssri first as I feel they have a much better side effect profile and I’ve had good results with it, and it makes sense to me since DMDD is conceptualized as a depressive disorder anyway.
  15. Information Underload

    Information Underload 2+ Year Member

    Aug 4, 2014
    It depends on how out of control the kid is. Rarely do I see severe cases of DMDD that respond to SSRIs. For more moody kids or anxious kids, sure. For kids who are throwing chairs, clearing classrooms, and having the police called, I haven't seen great results with SSRIs, particularly when there isn't a strong component of anxiety.
  16. PistolPete

    PistolPete Physician 10+ Year Member

    Jul 16, 2006
    What's your go-to atypical?

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