Metformin

[sunlioness]

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A patient told me today that she read a study online that talked about the use of metformin to prevent weight gain in patients taking antipsychotics. Does anyone know anything about this? Have any experience with trying it? It doesn't sound completely unreasonable to me.

 

[notdeadyet]

This wouldn't surprise me. There was talk at one point a couple of years ago of one of the atypical pharm companies combining metformin with their antipsychotic. I can't remember which or if it was abandoned or still being studied.

 

[flash]

Thanks for the reminder to learn more about this. I did a quick article review for the benefit of nursing staff, at the insistence of Attending, while I was an AI/Sub-I in med school, but had forgotten about it.

Places to start:

Björkhem-Bergman, Linda, Annika B. Asplund, and Jonatan D. Lindh. "Metformin for weight reduction in non-diabetic patients on antipsychotic drugs: a systematic review and meta-analysis." Journal of Psychopharmacology 25.3 (2011): 299-305.

http://jama.jamanetwork.com/article.aspx?articleid=1380162

 

[OldPsychDoc]

A patient told me today that she read a study online that talked about the use of metformin to prevent weight gain in patients taking antipsychotics. Does anyone know anything about this? Have any experience with trying it? It doesn't sound completely unreasonable to me.

We had a couple of patients admitted to us on metformin from a particular community doc who is known for being assertive about the "latest & greatest" and I admit it piqued my interest as well--especially as the risk and cost are going to be pretty danged low for this intervention.

Björkhem-Bergman, Linda, Annika B. Asplund, and Jonatan D. Lindh. "Metformin for weight reduction in non-diabetic patients on antipsychotic drugs: a systematic review and meta-analysis." Journal of Psychopharmacology 25.3 (2011): 299-305.

http://jama.jamanetwork.com/article....icleid=1380162

Pretty nice articles.
Look out residents! Coming to EBM workshop near you!

 

[FrasierMD]

http://ajp.psychiatryonline.org/article.aspx?articleID=1712524

Recent study from AJP just out in July. 16 week course on metformin found very modest effect for weight loss compared to placebo (and modest effects with secondary metabolic measures as well).

 

[billypilgrim37]

I've found it pretty helpful.

 

[SmallBird]

We have been doing this around here for certain patients, especially patients on Olanzapine. The data is reasonable and it seems to be well accepted in practise.

 

[FrasierMD]

We have been doing this around here for certain patients, especially patients on Olanzapine. The data is reasonable and it seems to be well accepted in practise.

Are you seeing a clinically significant advantage with it?

 

[birchswing]

I'm on an AAP with an A1C of 6.1, overweight, but not obese. My doctor wouldn't put me on metformin and wanted to "monitor" the situation (I only had the A1C done at my own insistence). Doctor would not diagnose diabetes. So, I started taking Cinnulin PF. My last A1C was 5.4, but no weight loss. I'm discontinuing the AAP slowly anyway (very slowly, though, as in over years).

 

[shan564]

I've seen at least 2-3 reliable studies showing benefit to metformin for weight gain when used with olanzapine, clozapine, and IIRC, risperidone. There was one in Am J Psych 1-2 months ago that was pretty well-designed and well-controlled. I'm too lazy to dig it up now.

 

[vistaril]

A patient told me today that she read a study online that talked about the use of metformin to prevent weight gain in patients taking antipsychotics. Does anyone know anything about this? Have any experience with trying it? It doesn't sound completely unreasonable to me.

?? This is fairly commonly done, especially with adolescents, so I'm pretty sure almost everyone knows about it. Heck even most of the internist types I know am aware of it. Now how much it helps...well that's more a matter of debate.

 

[nitemagi]

The literature has been floating around for about 5 years.

The short of it is that insulin resistance with antipsychotics actually comes before the weight gain.

Metformin may help with that insulin resistance, in maybe 30% of patients (last I looked at the literature).

 

[hamstergang]

?? This is fairly commonly done, especially with adolescents, so I'm pretty sure almost everyone knows about it

I just started my third year, and so far I have had one attending once mention metformin for weight loss, and I've seen 0 patients on metformin solely for weight loss. So the idea that it's commonly done and common knowledge does not seem to hold in the population I have access to.

 

[vistaril]

I just started my third year, and so far I have had one attending once mention metformin for weight loss, and I've seen 0 patients on metformin solely for weight loss. So the idea that it's commonly done and common knowledge does not seem to hold in the population I have access to.

Well I don't know what to say...the literature as others have mentioned has been out for awhile, and not in some obscure journals either. Even the op's patient(assuming a layperson) was aware of it. Most internists I know are aware of it. Now saying that I still choose not to do it(I think if I saw adolescents I would do it more).....

 

[MLT2MT2DO]

I just started my third year, and so far I have had one attending once mention metformin for weight loss, and I've seen 0 patients on metformin solely for weight loss. So the idea that it's commonly done and common knowledge does not seem to hold in the population I have access to.

Early 3rd year here as well have had 2 psych rotations so far. First never even mentioned it as an option to patients or at all. 2nd routinely prescribes it when weight gain is going to be a big deterrent to compliance. Abilify and Metformin, more common than peanut butter and jelly

 

[freaker]

There are multiple studies out there suggesting it to be the case. I've never had attendings who were willing to do it for whatever reason, even in patients very concerned about weight gain with family histories of diabetes.

http://www.ncbi.nlm.nih.gov/pubmed/21284696

 

[whopper]

Well others beat me to it, but there are published articles on it, giving one some framework to say there is something to it and they're not just making it up.

I haven't given it out yet for the reasons but it should be considered.

 

[hamstergang]

Now saying that I still choose not to do it(I think if I saw adolescents I would do it more).....

So why not?

 

[vistaril]

So why not?

1) It is one more med....for patients generally on a ton of meds already
2) It's not like the evidence it works is superduper great. Sure you can say the downsides/risk to adding it isn't that huge, but overall neither are the benefits

The real answer, imo, lies at looking at the risk/reward of having the pt on the psych med in the first place and not the endo med to maybe counteract side effects from the psych med

 

[MLT2MT2DO]

1) It is one more med....for patients generally on a ton of meds already
2) It's not like the evidence it works is superduper great. Sure you can say the downsides/risk to adding it isn't that huge, but overall neither are the benefits

The real answer, imo, lies at looking at the risk/reward of having the pt on the psych med in the first place and not the endo med to maybe counteract side effects from the psych med

A patient with schizo is already going to be a PITA as far as compliance with meds, why give them one more major reason (weight gain) to not take their meds.

I would think, even with the non-"super duper great" evidence, the placebo effect of the patient knowing they are on something to counter the weight gain would increase patient compliance.

 

[wolfvgang22]

Why not just use Topamax

 

[whopper]

I know there isn't much published stuff on it but almost every patient I've seen on a combo of Topamax and Depakote developed hyperammonemia and then encephalopathy as a result of it.

It hasn't been that many but when it was 100% of them (5/5) it's to the point where I don't exactly want to put anyone on that combo.

I onetime had to evaluate a case for the court where a girl was on both and became confused as heck and the psychiatrist didn't know what caused it. I called him to suggest he do an ammonia test but he never returned my calls. So here I am in court, telling the court I have a theory why she's delirious while her family is sitting there and the idiot doctor didn't show up to the hearing, all the while she's still on his unit for several days with no improvement.

But guess what? I'm not supposed to be treating her. So I can't order the ammonia test myself. I called the idiot again and he again never called me back. The family had to write down what I said and go to the hospital and ask him to do what the forensic evaluator suggested on doing in a situation like this.

 

[wolfvgang22]

Yeah, I wouldn't use both either. I think Topamax is interesting as an alternative to Depakote.

 

[vistaril]

Yeah, I wouldn't use both either. I think Topamax is interesting as an alternative to Depakote.

One of these days some pharmaceutical companies are going to want to try using Neurontin and Topomax as mood stabilizers.....they should both work good right?

 

[vistaril]

A patient with schizo is already going to be a PITA as far as compliance with meds, why give them one more major reason (weight gain) to not take their meds.

I would think, even with the non-"super duper great" evidence, the placebo effect of the patient knowing they are on something to counter the weight gain would increase patient compliance.

I just think the idea(in general) of adding meds to treat side effects is very unconvincing except in rare circumstances.

 

[notdeadyet]

I just think the idea(in general) of adding meds to treat side effects is very unconvincing except in rare circumstances.

I'd agree with this, except I'm a doctor.

 

[vistaril]

I'd agree with this, except I'm a doctor.[/QUOTE

??

 

[notdeadyet]

??

Fair enough, I was probably more flippant than clear.

If you can't find a medication that treats the primary symptoms without side effects, you have to treat the side effects. It's a pet peeve of mine when doctors finally stabilize a psych patient on medications and don't bother treating the side effects.

We snicker at our surgeon colleagues who talk about "the gall bladder in room 3," but bad psychiatrists are guilty of the same thing. We don't treat schizophrenia, we treat a patient with schizophrenia. We're responsible for the side effects we cause. I get very irritated when I inherit patients who are becoming diabetic, migrainous, or impotent without it being addressed.

Not treating impending diabetes because of an inclination to not add meds is bad medicine.

 

[masterofmonkeys]

http://ajp.psychiatryonline.org/article.aspx?articleID=1712524

Recent study from AJP just out in July. 16 week course on metformin found very modest effect for weight loss compared to placebo (and modest effects with secondary metabolic measures as well).

4.6 pounds in 4 months in a metabolically loaded population is not exactly 'modest'; it's actually a pretty robust effect. And this was on patients who were already on AAPs, had already had their metabolisms borked, and had already gained a lot of weight most likely. All this at a cost of 4 dollars a month and (potentially) a B12 supplement. 4 dollars for a 1lb/month loss in a population with the scales tipped against them (that pun was not intended but now I plan to leave it lol)? That's all sorts of yummy goodness.

Psych aren't the only people looking at expanding the use of metformin. PCPs are looking at it as well to use in people even before there's any evidence of insulin resistance or pre-diabetes, let alone frank DM2.

 

[billypilgrim37]

Welcome back, monkey!

 

[sunlioness]

Patient was back in this week and we decided to give it a shot. She isn't particularly heavy or diabetic now, but she's been on the medication we just put her on before and gained weight on it then. So we'll see what happens. She's also really watching her diet and exercise. Thanks for everyone's feedback.

And here's a little off topic venting . . . I'd be so much more inclined to post to this site if the "keep me logged in" check box kept me logged in for more than 10 minutes. And I wish that were an exaggeration. What gives, SDN? It didn't used to do that.

 

[hamstergang]

And here's a little off topic venting . . . I'd be so much more inclined to post to this site if the "keep me logged in" check box kept me logged in for more than 10 minutes. And I wish that were an exaggeration. What gives, SDN? It didn't used to do that.

I'm not having this problem, so I'd be hesitant to blame the site.