Obese patients on antipsychotics

[the5thelement]

Do you as a psychiatrist prescribe Ozempic or Zepbound for already obese patients ? What about starting metformin to prevent weight gain (according to the carlat article , metformin is better at preventing obesity /improving metabolic profile at the onset rather than in someone with established obesity.)

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[comp1]

I've definitely seen some psychiatrists play around with Metformin to occasional benefit. I haven't seen any psychiatrists mess with Ozempic yet, although I'm sure some do.

 

[brosa]

I've definitely seen some psychiatrists play around with Metformin to occasional benefit. I haven't seen any psychiatrists mess with Ozempic yet, although I'm sure some do.

Same here.

 

[the5thelement]

Do you as a psychiatrist prescribe Ozempic or Zepbound for already obese patients ? What about starting metformin to prevent weight gain (according to the carlat article , metformin is better at preventing obesity /improving metabolic profile at the onset rather than in someone with established obesity.)

This is the paragraph which got me thinking about prescribing it in patients without access to primary care :"metformin is our first-line preference as it helps not only with antipsychotic-related weight gain but also with the metabolic side effects of antipsychotics (insulin resistance, fasting glucose, triglycerides, and hyperprolactinemia), earning it a recommendation from the APA for this purpose. Metformin also has evidence in patients with a BMI ≥30 kg/m2. But neither it nor olanzapine/samidorphan can match the effects of GLP-1 RAs in patients with high BMIs after chronic antipsychotic use. "

 

[Merovinge]

I really think Metformin usage should be standard of care for Zyprexa, clozapine, maybe higher dosage Seroquel if there is any hint of uptick in weight upon initiation. I even end up using it with Abilify in kids as they gain far more weight than adults on the same dosage. I used to be lame and just want to refer to PCP/endo and wash my hands of it, but I've decided to get over my fears of Metformin and prescribe it myself. Hasn't been a problem yet over now several years of regular prescribing.

 

[jbomba]

I really think Metformin usage should be standard of care for Zyprexa, clozapine, maybe higher dosage Seroquel if there is any hint of uptick in weight upon initiation. I even end up using it with Abilify in kids as they gain far more weight than adults on the same dosage. I used to be lame and just want to refer to PCP/endo and wash my hands of it, but I've decided to get over my fears of Metformin and prescribe it myself. Hasn't been a problem yet over now several years of regular prescribing.

My understanding was that Seroquel associated weight gain was not necessarily dose dependent. Do you have a different understanding?

 

[Merovinge]

My understanding was that Seroquel associated weight gain was not necessarily dose dependent. Do you have a different understanding?

Yes, patient's I inherit on 25-50mg (I would almost never use this myself), have a very different experience than 300-600mg dosages. Not to say 25-50mg is benign, but certainly less than bipolar d/o range (where I regularly use it).

 

[Stagg737]

This is the paragraph which got me thinking about prescribing it in patients without access to primary care :"metformin is our first-line preference as it helps not only with antipsychotic-related weight gain but also with the metabolic side effects of antipsychotics (insulin resistance, fasting glucose, triglycerides, and hyperprolactinemia), earning it a recommendation from the APA for this purpose. Metformin also has evidence in patients with a BMI ≥30 kg/m2. But neither it nor olanzapine/samidorphan can match the effects of GLP-1 RAs in patients with high BMIs after chronic antipsychotic use. "

GLP-1s for metabolic effects are currently being researched as preliminary studies have been promising, but metformin is still the gold-standard for antipsychotic-related weight gain or metabolic syndrome. There are newer guidelines that argue it should be standard to start metformin when olanzapine or clozapine are started for patients with certain risk factors. Any psychiatrists afraid of prescribing metformin need to re-examine their prescribing practices imo. I've now seen multiple grand rounds on this subject now.

https://psychiatryonline.org/doi/10.1176/appi.pn.2025.02.2.8

My understanding was that Seroquel associated weight gain was not necessarily dose dependent. Do you have a different understanding?

Yes, patient's I inherit on 25-50mg (I would almost never use this myself), have a very different experience than 300-600mg dosages. Not to say 25-50mg is benign, but certainly less than bipolar d/o range (where I regularly use it).

Data is somewhat mixed. From how I interpret the data it looks like quetiapine does have both a risk of clinically significant weight gain at low doses (<100 mg) AND a dose-dependent risk of weight gain which is consistent with what I see in practice. I've seen patients gain 100+ pounds on quetiapine, but usually much less than that at lower doses where the gain is closer to 10-25 pounds.

 

[Candidate2017]

This is the paragraph which got me thinking about prescribing it in patients without access to primary care :"metformin is our first-line preference as it helps not only with antipsychotic-related weight gain but also with the metabolic side effects of antipsychotics (insulin resistance, fasting glucose, triglycerides, and hyperprolactinemia), earning it a recommendation from the APA for this purpose.

Starting Metformin is ok, but patients need to see a PCP. Severe psychiatric patients have a lot of medical comorbidities for which they need to get a PCP. This provides them boundaries and gets them to be responsible for their medical care. Plus, there is really no PCP shortage. IM, FM, NP, or PA can follow metabolic patients, refer to nutritionists, etc. If you have a patient on antipsychotics, there is a lot on your psychiatric plate. Playing PCP is cutting into your time as a valuable specialist handling psychosis or mania. The majority of Americans are overweight or obese anyway, with HLD etc.

 

[Atreides]

Metformin was standard of care where I trained for residency. We were expected to prescribe it liberally for AIMD.

I prescribe both semaglutide and tirzepatide. Will be sitting for obesity boards this year. I've met several psychiatrists who are comfortable prescribing GLP-1's and my academic institution is making a concerted push for psychiatrists to start using these medications. Saying there's no PCP shortage is laughable, they have a longer waitlist where I'm at than psychiatrists! My institution literally had to contract with Amazon to get enough primary care coverage for their own employees.

I purposefully don't advertise or list anywhere publicly that I prescribe these medications because I have no interest in becoming a weight loss clinic. I am interested in treating the side effects of the medications I prescribe as well as treating medical contributors to my patient's psychiatric conditions. My malpractice covers it so long as it falls under one of those two categories.

Obesity medicine is a growing field and I do firmly believe that psychiatrists can, and should, take a role in leading the field. We're uniquely equipped to treat obesity.

 

[MedMan80]

I've seen a psych prescribe ozempic to a BED patient

 

[clausewitz2]

I have multiple patients on tirzepatide primarily as a consequence of massive weight gain they experienced due to antipsychotics. I am doing this mostly in a first episode psychosis context so these are young people who have many years to have devastating consequences of morbid obesity so it seems rather imperative.

 

[comp1]

Yeah I gotta say...there is a PCP shortage and that includes NPs and PAs. I'm not sure if it's better or worse than the (severe) psychiatrist shortage, but there's definitely a shortage.

 

[FatherPsychiatry]

Will be sitting for obesity boards this year.

Interesting. Can you share you experience with this? Requirements etc? I'm looking at the website here:

Home - American Board of Obesity Medicine

The American Board of Obesity Medicine serves the public and the field of obesity medicine by maintaining standards for assessment and credentialing physicians.

www.abom.org

And it seems you need 60 CME credits on obesity, and then you're eligible to sit on the boards. Does that sound about right? I may be interested... I see tons of AIMD and there is definitely a shortage of primary care (or even interest) in caring for obesity here in this population.

 

[clausewitz2]

Interesting. Can you share you experience with this? Requirements etc? I'm looking at the website here:

Home - American Board of Obesity Medicine

The American Board of Obesity Medicine serves the public and the field of obesity medicine by maintaining standards for assessment and credentialing physicians.

www.abom.org

And it seems you need 60 CME credits on obesity, and then you're eligible to sit on the boards. Does that sound about right? I may be interested... I see tons of AIMD and there is definitely a shortage of primary care (or even interest) in caring for obesity here in this population.

30 of them need to be from a limited set of approved ABOM partners. At present this will set you back about $1500 on average.

 

[Stagg737]

30 of them need to be from a limited set of approved ABOM partners. At present this will set you back about $1500 on average.

The cost is worth noting, but the CME isn't difficult and is pretty straightforward to complete. I'm in the process of getting this started and one of my colleagues got certified last year. Per them it was quite easy to get certified at this point through the CME pathway and probably worth using professional funds (if you get them) on this if you want to be able to market this.

 

[FatherPsychiatry]

The cost is worth noting, but the CME isn't difficult and is pretty straightforward to complete. I'm in the process of getting this started and one of my colleagues got certified last year. Per them it was quite easy to get certified at this point through the CME pathway and probably worth using professional funds (if you get them) on this if you want to be able to market this.

Any particular CME you would recommend?

 

[Stagg737]

Any particular CME you would recommend?

Not personally. My colleague did the Harvard Blackburn Course which is a week long review course and knocked out all the CME at once. Said it was solid. I haven't done any through the website myself yet, but will probably look at the OMA or Columbia/Cornell courses since they're on-demand.

 

[Atreides]

Interesting. Can you share you experience with this? Requirements etc? I'm looking at the website here:

Home - American Board of Obesity Medicine

The American Board of Obesity Medicine serves the public and the field of obesity medicine by maintaining standards for assessment and credentialing physicians.

www.abom.org

And it seems you need 60 CME credits on obesity, and then you're eligible to sit on the boards. Does that sound about right? I may be interested... I see tons of AIMD and there is definitely a shortage of primary care (or even interest) in caring for obesity here in this population.

Yup, that website has all the info you need. Pretty straightforward; you do 60 CME credits, then take the boards. I'd pick one of their obesity courses (there are 4 options) rather than try cobbling together 60 CME. I did the Columbia on-demand option just because that's the first I clicked on. There's an Obesity Medicine Board Review Questions and Practice Test books on Amazon that I got too. I've been told that's more than enough for the exam, it's not supposed to be very difficult.

I think the bigger question is whether the boards are worth anything. In my case, I'm taking them because it's marginal extra effort to study for the exam (I learn best by studying for exams anyway) and because it gives me an extra layer of defense if someone tries to criticize me for prescribing these medications as a psychiatrist. My malpractice covers it regardless but I imagine if there's any medicolegal issues that ever arise, being board certified in obesity medicine definitively squashes any argument about this being outside my scope of practice.

 

[Stagg737]

Yup, that website has all the info you need. Pretty straightforward; you do 60 CME credits, then take the boards. I'd pick one of their obesity courses (there are 4 options) rather than try cobbling together 60 CME. I did the Columbia on-demand option just because that's the first I clicked on. There's an Obesity Medicine Board Review Questions and Practice Test books on Amazon that I got too. I've been told that's more than enough for the exam, it's not supposed to be very difficult.

I think the bigger question is whether the boards are worth anything. In my case, I'm taking them because it's marginal extra effort to study for the exam (I learn best by studying for exams anyway) and because it gives me an extra layer of defense if someone tries to criticize me for prescribing these medications as a psychiatrist. My malpractice covers it regardless but I imagine if there's any medicolegal issues that ever arise, being board certified in obesity medicine definitively squashes any argument about this being outside my scope of practice.

Yea, not sure what the utility for a lot of psychiatrists will be unless you want to start doing evals involving weight loss and market yourself as someone who will do therapy and Rx these. For me, it will help with status at my academic center, should help with a few research projects we are starting, and possibly open a few career doors here in one of the psych adjacent areas I'm interested in (metabolic/hormonal MH).

I've also got about $4k worth of CME money that I have to use by July or I'll lose it, so why not?

 

[FlowRate]

A small roadbump for me is that metformin isn't insurance covered for weight, so we're supposed to Rx to outside pharmacy and have patient pay cash price. Considering trying to push for seeing this as true preventative medicine/get an exemption to the weight thing for the case of concurrent AP use.

 

[WartsnAll]

Yeah I gotta say...there is a PCP shortage and that includes NPs and PAs. I'm not sure if it's better or worse than the (severe) psychiatrist shortage, but there's definitely a shortage.

isn’t the shortage more about distribution than an actual lack of PCPs? Most docs want to work in high cost-of-living areas, not in rural spots where the shortage is actually the worst. Plus, a lot are ditching insurance completely and going the DPC route which is probably driving the "shortage" more.
.
I'm sure it's similar with psychiatrist but not 100% sure

 

[Stagg737]

A small roadbump for me is that metformin isn't insurance covered for weight, so we're supposed to Rx to outside pharmacy and have patient pay cash price. Considering trying to push for seeing this as true preventative medicine/get an exemption to the weight thing for the case of concurrent AP use.

Is it covered for metabolic syndrome? Plenty of patients meet criteria for this even when not taking antipsychotics.

Even so, with GoodRx it’s often very cheap anyway. Just checked and I can get a 30 day supply for $2.00 at my grocery store pharmacy.

 

[Atreides]

isn’t the shortage more about distribution than an actual lack of PCPs? Most docs want to work in high cost-of-living areas, not in rural spots where the shortage is actually the worst. Plus, a lot are ditching insurance completely and going the DPC route which is probably driving the "shortage" more.
.
I'm sure it's similar with psychiatrist but not 100% sure

I don’t live in a rural area. Top five metros for physicians per capita. Still a massive PCP shortage, people prefer becoming specialists.

 

[psych50]

Ho does one sit for the obesity boards and would PRMS cover you for RXing metformin . ozempic and the like?

 

[comp1]

There are shortages everywhere. Rural can be worse, but things are bad in urban centers too.

 

[esob]

Have started some pts on metformin on our community health paid unit, since they cover it. I would love to see them cover compounded GLP's, but I doubt that it's happening anytime soon.

 

[ObsequiousAplomb]

Ho does one sit for the obesity boards and would PRMS cover you for RXing metformin . ozempic and the like?

Check your policy. They might have asked you a question about prescribing purely for weight loss or for weight loss in general. If it isn't clear from that, reach out and ask. Asking beforehand is free. Finding out in retrospect could be a disaster.