www.uchc.edu

METABOLIC SYNDROME IN A CORRECTIONS POPULATION TREATED WITH ANTIPSYCHOTICS

Andrew M. Cislo, PhDMegan J. Ehret, PharmD, MS, BCPP

Robert L. Trestman, MD, PhDKirsten Shea, MBA

Background

• Metabolic Syndrome: “…a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes”

• obesity, glucose intolerance, dyslipidemia, hypertension

• 3 or more risk factors for diagnosis

A.D.A.M. Medical Encyclopedia

Background

Risk Factor Defining Level

Abdominal obesity

Men >102 cm

Women >88 cm

Triglycerides >=150 mg/dL

HDL cholesterol

Men <40 mg/dL

Women <50 mg/dL

Blood Pressure >=135/>85 mm Hg

Fasting Glucose >=100 mg/dL

Table adapted from Grundy et al 2004; NCEP/ATPIII Guidelines

Background

• Community Prevalence of Metabolic Syndrome: 24-34%

• Physical Activity• Poor Nutrition• Substance Abuse• Smoking• Culture/Diet

Older ageGender * Race/ethnicityOverweight

Ford 2002; ADA 2004; Holt 2004; Petty 2003; Ervin 2009

Background

• Are these risk factors similarly distributed in community and prison populations?

•No!

• Younger, great majority male, over-representation of minorities, adequate nutrition, very limited substance use, no smoking

• Also – Over-representing SMI

Background

• Rates of MS significantly higher among SMI• ~41%

• Second generation, or atypical, antipsychotics associated with increased MS risk

McEvoy et al 2005

Background

ClozapineOlanzapineQuetiapineRisperidonePaliperidone

AripiprazoleLurasidoneIloperidoneZiprasidoneAsenapine

Stahl SM 2009; De Hert M 2009; Nussbaum 2008; Scott LH 2009; Meltzer HY 2009; Weber J 2009

Background

• Correctional Managed Health Care (CMHC) at UConn Health Center

• Responsibility for all global medical, mental health, pharmacy, and dental service provision in integrated jail and prison system.

• 2 phase project• Administrative data alone (described below)• Medical chart review to enable use of NCEP/ATP III

Guidelines

Background

• Two Major Contributions

• First study of MS prevalence by antipsychotics with incarcerated population

• Individual variation (with environmental controls)

• Method: Compare MS measurement criteria• Traditional• Modified (for use with existing electronic

data)

Background

• UConn IRB approval

• Awaiting CT DOC determination

Research Questions

Are atypical antipsychotics generally associated with elevated risk for MS in corrections?

Does Rx risk for MS align with relative risk in community studies?

Method

CMHC e-pharmacy records July 2010-June 2012

Inclusion Criteria Qualifying 1st or 2nd generation antipsychotic

Rx fill during window Received med. for at least 6 months If fills in both gens (not concurrently):

First med. if >=6 months & 1 fill in window

Method

Exclusion Criterion No med in other generation concurrently

Method

Analytic Categories

First Gen Only Second Gen Only

First to Second Gen Second to First Gen

Method

Dependent Variable Metabolic Syndrome

>=3 of the following BMI>=25 Rx lipid modifying agent Rx antihypertensive medication Rx diabetic medication

(Einhorn D. 2003, Lambert BL 2005, Lambert BL 2005)

Method

• Other Covariates• Race/ethnicity• Gender• Age• Time since admission

• Anovas and Logistic Regressions

Sample Description (N=X)% Race/Ethnicity

White Black Hispanic

% Age Group<40 years 40+ years

% SexMale Female

Sample Description (N=X)

% Rx Generation First Gen Only Second Gen Only First to Second Second to First

% Ever 2nd GenEver Second

% Outcome

Metabolic Syndrome

Limitations

• Time ordering

• Sequencing of Rx history

• Window and sample size

• Administrative data

• Lack of randomization

Future Directions

• Medical chart reviews required• Height/weight (more complete)• Lab values: glucose, cholesterol panels• Sequencing of antipsychotic Rx

• Inclusion of additional medications• Mood stabilizers- lithium, valproic acid• Antidepressants

• Stratify by psychiatric Dx

Future Directions

Replication

Do other states have comparable electronic data for comparison?

www.uchc.edu

Contact Information

Andrew M. Cislo, PhDDirector of Research and EvaluationCorrectional Managed Health Care

University of Connecticut Health Center263 Farmington Avenue, ASB Bldg., 3rd floor

Farmington, CT 06030-5386Phone: 860-282-8575Email: cislo@uchc.edu