Performance Improvement Project

Increase the Proportion of Metabolic Syndrome Screening In Adults with Severe Mental Illness receiving "atypical” second generation antipsychotics

Study Indicator: The percentage of consumers who are prescribed “atypical” second generation antipsychotic medication and are also monitored for metabolic syndrome by having at least one of the Adult Treatment Panel (ATP) III measures completed during the measurement period.

Purpose: Identify consumers at risk of developing Diabetes and

Cardiovascular disease by monitoring for Metabolic Syndrome when prescribing “atypical” second generation antipsychotic medications. By identifying these consumers, MCCMH staff will initiate and conduct activities conducive to prevent, minimize, and manage risks associated with “atypical” second generation antipsychotic use in consumers with severe mental illness.

  Goal: Improve process and outcomes of health care delivery by early

identification of indicators of metabolic risk which can lead to Diabetes

Performance Improvement Project

“Atypical” Second Generation Antipsychotic Medications: Abilify (Aripiprazole), Clozaril (Clozapine), Geodon (Ziprasidone), Invega (Paliperidone), Risperdal (Risperidone), Risperdal Consta, Seroquel (Quetiapine) and Zypreza (Olanzapine)

Second Generation Antipsychotics

Adults with serious mental illness, commonly treated with second-generation antipsychotic (SGA) drugs, have up to two-times-greater prevalence of type 2 diabetes, dyslipidemia, hypertension, and obesity.

Cardiovascular disease is the leading contributor to mortality for adults with serious mental illness resulting in a decades less life expectancy than the general population

Effects of Second Generation Antipsychotic Drugs

Increased risk for premature cardiovascular mortality has been attributed to lower socioeconomic status, physical inactivity and poor dietary choices, obesity, greater smoking and substance abuse, adverse medication effects, and underutilization of primary and secondary prevention.

Unfortunately, diabetes and cardiovascular

risk is often under recognized and undertreated in patients with mental illness.

Effects of Second Generation Antipsychotic Drugs

Metabolic Syndrome is a group of risk factors present in a single individual that promote the development of coronary artery disease, stroke, and Type 2 Diabetes.

The symptoms of Metabolic Syndrome include: unhealthy cholesterol levels, high blood pressure, high blood sugar, and excess belly fat (waist circumference over 35" for women and 40" for men).

Metabolic Syndrome

Those with Metabolic Syndrome are at risk of serious health problems including heart attack, stroke and Diabetes. In fact, the chance for Diabetes can be as much as five times higher than in the general public.

A person is said to have Metabolic Syndrome when elevations of the above measurements are present along with the increased waist size. Thus, it's the combination of the four criterions that leads to the most risk.

Metabolic Syndrome

ATP III Criteria for Clinical Identification of Metabolic Syndrome any 3: Per recommendation from the Mount Sinai Conference: measurement of fasting plasma glucose level is preferred but measurement of Hemoglobin A1C is acceptable if a fasting plasma glucose test is not feasible

Risk Factor Indicator

Abdominal Obesity Men Woman

Waist Circumference > 102 cm (>40 inches) > 88 cm (>35 inches)

Fasting Triglycerides >=150 mg/d1

Fasting HDL Cholesterol Men Woman

<40 mg/dl <50 mg/dl

Fasting Glucose( Hgb A1C can also be done)

>= 110 mg/dl or medication treatment

Blood Pressure >= 130/85 mm Hg or medication treatment

ATP III Criteria

  Measure Baseline 4-weeks 8-weeks 12-weeks Annually

  Personal/family history X X

 

Weight (Body Mass

Index-BMI)X X X X X

  Waist circumference X X

Blood pressure X X X

Fasting blood glucose X X X

Fasting lipid profile X X X

The following chart was the recommended schedule for monitoring patients on “atypical” second-generation antipsychotics

Measure Baseline 4-weeks 8-weeks 12-

weeksQuarterl

yAnnuall

yMedical and Family

history including

CVD

X X

Weight (Body Mass

Index-BMI)X X X X X X

Waist circumference X X

Blood pressure X X X

Hemoglobin A1C X

Random blood

glucoseX X X

Non-fasting Total

Cholesterol and HDLX X X

The following chart is the revised schedule for monitoring patients on “atypical” second-generation antipsychotics

Generic (Trade Name)

Weight Gain Dyslipidemia Hyperglycemia Metabolic Syndrome

Aripiprazole (Abilify)

Low Low Low Low

Clozapine (Clozaril)

High High High High

Olanzapine (Zyprexa)

High High High High

Quetiapine (Seroquel)

Moderate High Moderate Moderate

Risperidone (Risperdal)

Mild-Moderate Mild Mild Mild

Ziprasidone  (Geodon)

Low Low Low Low

Second Generation Antipsychotics and their risks

Case Managers need to instruct consumers on medication risks including information on Metabolic Syndrome as well as information on the particular medication that they are on. Consumer Information is posted on the share point site and information on the medications can be found in FOCUS under the Medical Tab patient education heading. You can search under either Medication or Diagnoses.

What does this mean to me?

Physicians need to: (1)Ensure the appropriate psychiatric

diagnosis is made. (2) Consider target symptoms, approved

indications, and degree of functional impairment before initiating treatment.

(3) Monitor all patients on an “atypical” second-generation antipsychotic according to approved protocol.

(4) Encourage preventive lifestyle practices.

What does this mean to me?

Physicians need to educate themselves on Metabolic Syndrome and the necessity of monitoring for its potential occurrence.

Physicians need to educate the consumers and their families/caregivers on the medications they are taking as well as the risk of metabolic syndrome.

What does this mean to me?

Physicians need to monitor consumers using the ADA/APA Screening Guidelines and if consumers exceed the cut-off, they need to contact the consumer’s PCP to coordinate an appropriate course of treatment.

Staff within the agency: Case Managers, Nurses, Physicians, etc. need to make sure that consumers have their blood work as well as weight-BMI, BP, and waist circumference measured at the time the medication is initiated and throughout the course of time that the consumer is on the medication.

What does this mean to me?

Consider working with the consumer on health goals related to the medication and its side effects. For example: encouraging preventive lifestyle practices such as improving diet and exercise habits; making sure that blood work is completed on monitoring schedule; referring to dietitian, weight loss program, etc.

What does this mean to me?

Questions or Suggestions

If you have any questions or suggestions, please feel free to contact me at 586-948-6169 or sue.gough@mccmh.net