Part 4 ? Second generation antipsychotic medications

Independence and Magellan Healthcare, Inc. (Magellan) have been encouraging all primary care physicians and behavioral health providers to communicate with each other about their patients. This is one example of a crucial need to make sure ongoing communication occurs.

Second generation antipsychotic (SGA) medications, also known as atypical antipsychotic medications, have been used in psychiatry since 1990 when clozapine (Clozaril^®) was approved for treatment-resistant schizophrenia. Today, these medications are being prescribed by providers of many specialties, not just psychiatry.

As more medications for this class of drugs are being developed, we expect use of these medications to continue. Use of these medications is prompted by their association with fewer anticholinergic and movement side effects than the typical antipsychotic medications such as haloperidol (Haldol^®). These side effects are very uncomfortable for patients. However, SGAs have presented other side effects, known as Metabolic Syndrome.¹ Metabolic Syndrome includes hyperglycemia, hyperlipidemia, hypertension, and increase in weight. Current literature does not show that Metabolic Syndrome is dose- or time-related,² so all providers who prescribe an SGA need to monitor for Metabolic Syndrome.

Monitoring for Metabolic Syndrome

The current SGA medications approved by the U.S. Food and Drug Administration include:

aripiprazole (Abilify^®)
asenapine (Saphris^®)
clozapine* (Clozaril^®)
iloperidone (Fanapt^®)
lurasidone (Latuda^®)
olanzapine (Zyprexa^®)
olanzapine/fluoxetine (Symbyax^®)
paliperidone (Invega^®)
quetiapine (Seroquel^®)
risperidone (Risperdol^®)
ziprasidone (Geodon^®)

The chart below shows monitoring protocols that are recommended by the American Diabetes Association and American Psychiatric Association.³ More frequent assessments may be warranted based on clinical status.

All prescribing providers should explain the need for this monitoring as well as the potential side effects whenthey discuss treatment with their patients and request their informed consent. Independence and Magellan have collaborated to provide practitioners with information on atypical antipsychotic medication management, including a patient handout to educate your patients on antipsychotic medication management and potential risks. You can access this information on our website.

*Alert: Clozapine is also associated with agranulocytosis and in order to dispense this medication, the pharmacy must have an Absolute Neutrophil Count (ANC) on file.⁴ When a provider prescribes clozapine, not only do they need to monitor for Metabolic Syndrome as recommended but the ANC must be drawn weekly for the first 6 months, then every 2 weeks for the next 6 months. If the patient is taking the medication for one year, the ANC only needs to be drawn monthly.

¹ DeHert, M., et al (2012). ?Metabolic and cardiovascular adverse effects associated with antipsychotic drugs.? Nature Reviews Endocrinology. Vol 8: 114-126.
² Liao, T.V. & Phan, S.V. (2014). ?Acute hyperglycemia associated with short term use of atypical antipsychotic medication.? Drugs. 74:2, 183-194.
³ American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. ?Consensus development conference on antipsychotic drugs and obesity and diabetes.? Diabetes Care, 2004; 27: 596-601.
⁴ Clozaril REMs Program: A single shared system for Clozapine. May 20, 2016.

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.