importance of monitoring comorbidities in patients with ... psych grand... · importance of...

SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCESDEPARTMENT OF MEDICINE

Importance of Monitoring Comorbidities in

Patients with Mental Illness

Ajay Chaudhuri, MBBS, MRCP (UK)

Clinical Professor, Department of Medicine

Program Director, Endocrinology Fellowship

UB|MD Internal Medicine – Endocrinology,

Diabetes & Metabolism

Director, Kaleida’s Diabetes & Endocrinology

Center of WNY, President WNY ADA

1. CDC. Available at: http://www.cdc.gov/diabetes/statistics/slides/maps_diabetes_trends.pdf. Accessed Nov 7, 2008.2. CDC. Available at: http://www.cdc.gov/media/pressrel/2007/r071128.htm. Accessed Nov 7, 2008.3. NDIC. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/DM_Statistics.pdf. Accessed Nov 7, 2008.

Percentage of US Adults With Diagnosed Diabetes1*

Multiple factors contribute to the increasing prevalence of diabetes

Aging population

Increasing obesity: 72 million Americans were obese in 2005-2006 (BMI 30)2

Growing population of people of non-Caucasian ethnicity

24 million Americans have diabetes3

6 million are undiagnosed3

90-95% of the diagnosed population have type 2 diabetes3

19972002 <4.5%

4.5-5.9%

6.0-7.4%

7.5-8.9%

9%

2007 1997 2002

<4.5 4.5-5.9% 6.0-7.4% 7.5-8.9% 9%

2007

*Age adjusted. BMI=body mass index.

The Diabetes Epidemic: Global Projections, 2010–2030

IDF. Diabetes Atlas 5th Ed. 2011

Disease Burden of Type 2 Diabetes

• Macrovascular disease

– 2- to 4-fold more likely to have heart disease or stroke

– 2- to 8-fold more likely to have heart failure

– Accounts for 60% to 70% of all diabetes-related deaths

– Lower extremity amputations

• Microvascular disease

– Up to 24,000 new cases of blindness annually

– Leading cause of end-stage renal disease

– Neuropathy (including erectile dysfunction)

Centers for Disease Control and Prevention. National Diabetes Fact Sheet. 1998.

American Heart Association. 2001 Heart and Stroke Statistical Update.

National Heart, Lung, and Blood Institute. Facts about heart failure. 1997, online edition.

Impact of Mental Illness and Diabetes on Life Expectancy, Morbidity, and Mortality

Diabetes was the 7th leading cause of death in the US in 20061

The risk of premature death among people with diabetes is ~2x greater than for thosewithout diabetes of a similar age1,2

The Framingham Heart Study indicated diabetes decreases life expectancy by ~8 years2

Average potential years of life lost due to mental illness range from 13 to 30 years3

A major contributor to premature deaths is cardiovascular disease3

Individuals with severe mental illness have ~1.5 to 2x more diabetes and obesity than the general population4-7

1. NDIC. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/DM_Statistics.pdf. Accessed Nov 7, 2008.

2. Franco O, et al. Arch Intern Med. 2007;167(11):1145-1151.3. Colton C, Manderscheid R. Prev Chronic Dis. 2006;3(2):A42.

MENTAL ILLNESSDIABETES

4. Dixon L, et al. Schizophr Bull. 2000;26(4):903-912.5. Mukherjee S, et al. Compr Psychiatry. 1996;37(1):68-73.6. Fagiolini A, et al. Bipolar Dis. 2005;7:424-430.7. ADA. Diabetes Care. 2004;27(2):596-601.

CATIE: Baseline Prevalence of Risk Factors for Medical Comorbidities

Mortality and Medical Comorbidity Among Patients With Serious Mental Illness

Miller B, et al. Psychiatr Serv. 2006;57(10):1482-1488.

Comorbidities Among Patients for

Whom Underlying Cause of Death

Was Heart Disease (n=126)*

Causes of Death Among Patients

Admitted to Mental Health Hospital

Between 1998 and 2002 (n=608)

Unclassified (5%) Cancer (7%)

Suicide (18%)

Pneumonia/Influenza (3%)

Chronic Lower Respiratory Disease (5%)

Accidents (14%)

Diabetes (3%)

Homicide (2%)

Cerebrovascular Disease (2%)

Other Causes (20%)

100

30

20

10

0

Heart Disease

(21%)

Hypertension Obesity Diabetes COPD Dyslipidemia

37%34%

19%

10% 9%

% o

f P

ati

en

ts W

ith

Co

mo

rbid

ity

*With Axis III diagnosis.

COPD=chronic obstructive pulmonary disease.

PREDIABETES1 METABOLIC SYNDROME2,3

(Defined as having 3 traits)

IFG: ↑ FBG

100-125 mg/dL

IGT: ↑ 2-hr OGTT

140-199 mg/dL

↑ FBG

100 mg/dL

↓ HDL

<40 mg/dL (M),

<50 mg/dL (F)

↑ Triglycerides

150 mg/dL

↑ Waist circumference

>40 inches (M)

>35 inches (F)

↑ BP

130/≥85 mm Hg

Prediabetes, Metabolic Syndrome, and Cardiometabolic Risk

1. ADA. Diabetes Care. 2008;31(suppl 1):S12-S54.2. Adult Treatment Panel. JAMA. 2001;285(19):2486-2497.3. Grundy SM, et al. Circulation. 2005;112:2735-2752.

Poor Diet

↑ Triglycerides

Overweight/

Obesity

Sedentary

Lifestyle

HypertensionInflammation/

Hypercoagulation

Age, Race,

Gender

Smoking

Family

History

↓ HDL

↑ LDL

↑ FBG

Insulin

Resistance

CARDIOMETABOLIC RISK4

The overall risk of developing type 2 diabetes and cardiovascular diseases

due to a cluster of risk factors

IFG=impaired fasting glucose. FBG=fasting blood glucose. IGT=impaired glucose tolerance. OGTT=oral glucose tolerance test. BP=blood pressure. HDL=high density lipoprotein. LDL=low density lipoprotein.

4. ADA. Available at: http://www.diabetes.org/for-health-professionals-and-scientists/cardiometabolic-risk.jsp. Accessed Nov 10, 2008.

Baseline 4 Weeks 8 Weeks 12 Weeks AnnuallyEvery 5

Years

Personal family history X X

Weight (BMI) X X X X

Waist circumference X X

BP X X X

Fasting plasma glucose X X X

Fasting lipid profile X X X

American Diabetes Association (ADA) Screening Guidelines for Patients on SGAs

ADA. Diabetes Care. 2004;27(2):596-601.

More frequent assessments may be warranted based on patient results and the monitoring recommendations in the package inserts for individual antipsychotic drugs used.

CASE SCENARIO #2

Unresponsive to current antipsychotic

medication for severe mental illness

IFG (Prediabetes)

Smoker (2 packs/day)

Recent weight gain

How does IFG impact your treatment decisions?

Is this patient at significant risk for developing diabetes?

How can the psychiatrist most appropriately manage this patient from this point forward?

CASE SCENARIO #3



Suicidal ideation

History of cardiovascular disease and type 2 diabetes

Sedentary lifestyle

What are your treatment priorities?

How can the psychiatrist collaborate with other healthcare professionals to most appropriately monitor this patient?

What Is the Appropriate Course of Action?

CASE SCENARIO #1

Severe mental illness is well controlled

Good overall health

No significant cardiometabolic risk factors

Family history of diabetes

What type of monitoring (if any) is necessary for this patient?

Baseline 4 Weeks 8 Weeks 12 Weeks AnnuallyEvery 5

Years

Personal family history X X

Weight (BMI) X X X X

Waist circumference X X

BP X X X

Fasting plasma glucose X X X

Fasting lipid profile X X X

American Diabetes Association (ADA) Screening Guidelines for Patients on SGAs

ADA. Diabetes Care. 2004;27(2):596-601.

More frequent assessments may be warranted based on patient results and the monitoring recommendations in the package inserts for individual antipsychotic drugs used.

Criteria for the Diagnosis of Diabetes

A1C ≥6.5%

OR

Fasting plasma glucose (FPG)≥126 mg/dL (7.0 mmol/L)

OR

2-h plasma glucose ≥200 mg/dL(11.1 mmol/L) during an OGTT

OR

A random plasma glucose ≥200 mg/dL (11.1 mmol/L)

ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

Screening For Diabetes

Testing at least every 3 yrs starting at age 45

American Diabetes Association. Diabetes Care. 2014:37, S14-80

Test Prediabetes Diabetes

FPG 100-125 mg/dL ≥126 mg/dL

OGTT 140-199 mg/dL ≥200 mg/dL

A1C 5.7-6.4% ≥6.5%

Younger/More Frequent Testing

If patient is overweight or obese and has 1 or more of the following risk factors (or 2 if not overweight):

1st degree relative with diabetes

Physically inactive

Certain race/ethnicity

Elevated blood glucose

Hypertension

Low HDL cholesterol and/or high triglyceride level

History of GDM

Delivering baby weighing >9 lbs

Polycystic ovary syndrome (PCOS)


Natural History of Type 2 Diabetes

Adapted from: Simonson GD, Kendall DM. Coron Artery Dis. 2005;16(8):465-472.

Years

Glu

co

se

(m

g/d

L)

Re

lati

ve

Fu

nc

tio

n (

%)

-10 -5 0 5 10 15 20 25 30

50

100

150

200

250

300

350

Clinical Diagnosis

Insulin Resistance

-Cell Function

Postmeal Glucose

Fasting Glucose

Prediabetes (IFG, IGT)

0

50

100

150

200

250

Onset of

Diabetes

Slide Source:

Lipids Online Slide Librarywww.lipidsonline.org

Reprinted with permission from DeFronzo R et al. Diabetes. 2009;58:773-795. Copyright © 2009 American Diabetes Association. All rights reserved.

Ominous Octet

IncreasedHGP

Hyperglycemia

ETIOLOGY OF T2DM

DEFN75-3/99 Decreased GlucoseUptake

Impaired InsulinSecretion Increased Lipolysis

Decreased

Incretin Effect

Decreased InsulinSecretion

IncreasedHepatic Glucose

Production

Islet– cell

IncreasedGlucagonSecretion

Decreased Glucose

Uptake

Increased Lipolysis

Increased

Glucose

Reabsorption

HYPERGLYCEMIA

NeurotransmitterDysfunction

Insulin Resistance in Treatment-Naïve Patients With Schizophrenia

Ryan MCM, et al. Am J Psychiatry. 2003;160(2):284-289.

Ins

uli

n (

U/m

L)

Co

rtis

ol (n

mo

l/m

L)

Ins

uli

n R

es

ista

nc

e(H

OM

A)

P<0.01

P<0.05

P<0.005

P<0.03

Glu

co

se (

mg

/dL

)

HOMA=homeostasis model assessment.

Schizophrenia AND Diabetes


Genetic predisposition

≤3.5

≥46.0

Hu FB, et al. Arch Intern Med. 2001;161(12):1542-1548.

Sedentary Lifestyle Increases the Risk for Development of Diabetes

Quartiles of Hours/Week

Spent Watching TV

Quartiles of MET-

Hours/Week

Spent on Physical

Activity

Re

lati

ve

Ris

k

>15.0 8.1-15.0 3.6-8.0

23.6-45.9

10.0-23.5

<10.0

MET-hours=metabolic equivalent hours.


Effect of Antipsychotic drugs

CASE SCENARIO #2



IFG (110 mg/dL, prediabetes)


Recent weight gain



How can the psychiatrist most appropriately manage this patient from this point forward?

CASE SCENARIO #3



Suicidal ideation


Sedentary lifestyle




CASE SCENARIO #1


Good overall health




Prediabetes

Prediabetes is an important risk factor for future diabetes and cardiovascular disease

Studies have shown that lifestyle modification can reduce the rate of progression from prediabetes to diabetes


Cu

mu

lati

ve

In

cid

en

ce

of

Dia

bete

s (

%)

Years

40

30

20

10

0

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Placebo

Metformin

Lifestyle

Knowler WC, et al. NEJM. 2002;346:393-403

Diabetes Prevention Program

Older Adults(Cases/100 person-yrs)

Placebo 10.8

Metformin 9.6

Lifestyle 3.1

A1C ≥ 6.0%IFG and IGT

+ Other Features

Lifestyle intervention and/or metformin, follow-up @6 mo

Intervention and Follow-Up

Screen for Diabetes:A1C - or -FPG – or -

2-hour, 75-g OGTT

Normal

Re-evaluate in 3 years if risk

factors remain

METFORMIN IS NOT FDA APPROVED FOR PREVENTION


Lifestyle intervention,

follow-up @1 year

A1C ≥ 5.7%IFG or IGT

DIABETES

Lifestyle intervention plus metformin,follow-up @3 mo

Patients With Severe Mental Illness Can Benefit From Lifestyle Modifications

Behavioral strategies

Self-monitoring of eating

Physical activity

Stress management

Nutrition principles

Meal planning

Label reading

Portion size

Healthy snacking

Exercise

Light to moderate for 20 minutes, 3-5 times/week

Menza M, et al. J Clin Psychiatry. 2004;65(4):471-477.

Weight Loss After a Year-Long Participation in “Healthy Living” Program

Month

*P=0.005 vs usual care

BM

I

Intervention (n=31) Usual care (n=23)

*

Patients With Severe Mental Illness Who Were Enrolled in a Solutions for Wellness Personalized Program Lost Weight

Based on changes in weight as reported on returned follow-up surveys

Individual results may vary

Hoffmann VP, et al. J Clin Psychiatry. 2005;66(12):1576-1579.Hoffmann VP, et al. Presented at: APA; May 1-6, 2004: New York, NY.

Imp

rove

me

nt

(n=2666) (n=1916) (n=1599) (n=1252) (n=872)

Me

an

Ch

an

ge

in

BM

I

Follow-Up 2:

Week 7

Follow-Up 3:

Week 11

Follow-Up 4:

Week 15

Follow-Up 5:

Week 19

Follow-Up 6:

Week 22

CASE SCENARIO #3



Suicidal ideation


Sedentary lifestyle




CASE SCENARIO #1


Good overall health




CASE SCENARIO #2



IFG (110 mg/dL, prediabetes)


Recent weight gain



How can the psychiatrist appropriately manage this patient from this point forward?


Management of diabetes


1993-1997 2005-2010


SUMMARY OF THE LANDMARK

CLINICAL TRIALS

• Intensive glycemic control reduces

microvascular complications

• Intensive glycemic control reduces

macrovascular complications

• shorter duration of diabetes

• without established CVD

• In long term follow up studies

0

10

20

30

40

50

60

COMPOSITE ENDPOINT OF DEATH FROM CV CAUSES, NONFATAL MI, CABG, PCI, NONFATAL STROKE, AMPUTATION, OR SURGERY FOR PAD: STENO-2

Prim

ary

Com

posite

Endpoin

t (%

)

Months of Follow-up

0 24 48 60 9636 847212

Conventional Therapy

Intensive Therapy

P=0.007

Hazard ratio = 0.47 (95% CI, 0.24–0.73; P=0.008)

Gæde P et al. N Engl J Med 2003;348:383-393. Copyright 2003 Massachusetts Medical Society. All rights reserved.

53%


ABC OF DIABETES CARE

A A1C

B Blood pressure

C Cholesterol

Slide Source:

Lipids Online Slide Librarywww.lipidsonline.org

Reprinted with permission from DeFronzo R et al. Diabetes. 2009;58:773-795. Copyright © 2009 American Diabetes Association. All rights reserved.

Ominous Octet

IncreasedHGP

Hyperglycemia

ETIOLOGY OF T2DM

DEFN75-3/99 Decreased GlucoseUptake

Impaired InsulinSecretion Increased Lipolysis

Decreased

Incretin Effect

Decreased InsulinSecretion

IncreasedHepatic Glucose

Production

Islet– cell

IncreasedGlucagonSecretion

Decreased Glucose

Uptake

Increased Lipolysis

Increased

Glucose

Reabsorption

HYPERGLYCEMIA

NeurotransmitterDysfunction

SGLT2

inhibitor

Incretins

BromSR


ANTIDIABETES THERAPY: TREATMENT

EFFECTS1,2

Class

Expected Decrease in A1C

(%)

Biguanides 1 – 2

Sulfonylureas 1 – 2

Glinides 0.5 – 1.5

Alpha glucosidase inhibitors

0.5 – 0.8

Thiazolidinediones

0.5 – 1.4

DPP-IV inhibitors 0.5 – 0.8

GLP-1 receptor agonists

0.5 – 1.5

Insulin 1.5 – 3.51. Nathan DM et al. Diabetes Care. 2009;32(1):193-203.

2. American Association of Clinical Endocrinologists. Endocrine Practice. 2007;13:3-68.

SGLT2 inhibitor 0.6 to 1.1%


• Individualize glycemic goals based on patient

characteristics and avoid hypoglycemia

• Promptly intensify antihyperglycemic therapy to maintain

blood glucose at individual targets

• Combination therapy necessary for most patients

• Base choice of agent(s) on individual patient medical history, behaviors and risk factors, ethno-cultural

background, and environment

• Insulin eventually necessary for many patients

• SMBG vital for day-to-day management of blood sugar

• All patients using insulin

• Many patients not using insulin

Common Principles in AACE/ACE and

ADA/EASD T2DM Treatment Algorithms

importance of monitoring comorbidities in patients with ... psych grand... · importance of...

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