Transcript Slide 1

Blood Glucose Control in a
Schizophrenic Population in
an Outpatient Setting
Daniel Molloy, MD
James Stephen, MD
Schizophrenia
• Characterized by a heterogeneous mixture
of clinical features  psychosis (1).
• Incidence: 10 to 40 / 100,000 population
• High risk for poverty, unemployment,
homelessness or inadequate housing, ill
health, and poor access to health care.
Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H.
Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds), CURRENT Diagnosis & Treatment:
Psychiatry, 2e.
Background
• Potentially devastating socioeconomic
consequences.
• Medical effects(2):
20% decreased life expectancy
Increased rates of cardiovascular and
metabolic abnormalities
Unhealthy lifestyle (high rates of
smoking/substance abuse)
McGrath J, Saha S, Welham J, El Saadi O, Macauley C, Chant D. “ A systematic review of the
incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status
and methodology.” BMC Med . 2:13 (2004).
Background
• Per DSM – IV TR (3), the
 delusions
 hallucinations
 disorganized speech and/or behavior,
 negative symptoms (alogia, avolition, and flat affect).
 This must be at least 6 months in duration and
produce disturbances in work, self-care, and
interpersonal relations.
American Psychiatric Association. DSM-IV. Diagnostic and statistical manual of mental disorders. 4th ed.
Washington: American Psychiatric Association, 1994: 273-315
Background
• in 1887, Schizophrenia was first described
as a distinct illness by Emil Kraeplin.
Dementia Praecox
• 1911 Bleuler first used the term
“schizophrenia”
Rationale
• Bias influences healthcare provider
decision making (4).
• Study with standardized patient showed
HCP less likely to prescribe appropriate
therapies/medications to schizophrenic
patients(4).
• Also includes mental health professionals
(4).
Mittal, Dinesh, MD. "Does Serious Mental Illness Influence Treatment Decisions of Physicians and
Nurses?" Lecture. American Psychiatric Assocation 2012 Annual Meeting. San Francisco. 20 May
2013. APA 166th Meeting. American Psychiatric Association, May 2013
Hemoglobin A1c
• Formed by the irreversible, nonenzymatic
binding of glucose to hemoglobin
• Serves as a predictable measure of
average blood glucose over period of 90 –
120 days.
• ADA Clinical Practice Recommendations
now recommend using HbA1c to diagnose
diabetes using a NGSP-certified method
and a cutoff of HbA1c ≥6.5%(5).
Diabetes Care January 2012 vol. 35 no. Supplement 1
S11-S63
Hemoglobin A1c
• Limitations to hemoglobin A1c:
Dependent on lifespan of RBC
Influenced by hemoglobin variety
Laboratory –dependent  standardization
Antipsychotic medications
• Antipsychotic medications commonly used
in the treatment of schizophrenia have a
well – documented tendency to cause
hyperglycemia and/or insulin resistance
(6).
• Particularly pronounced in patients
receiving certain members of the class of
second – generation antipsychotics(6).
• Cause is unclear, likely multifactorial
Gautam, S., and PS Meena. "Drug-emergent Metabolic Syndrome in Patients with Schizophrenia
Receiving Atypical (second-generation) Antipsychotics." Indian Journal of Psychiatry 53.2 (2011): 128-33
Aims
• Primary Objective: To determine whether a
difference in average blood glucose control
exists between a schizophrenic and a non schizophrenic population in an outpatient
setting.
• Secondary Objectives:
• To determine whether an association
exists between A1c levels and the number
of healthcare contact events during study
period.
• To assess the prevalence of vascular
disease between schizophrenic and non –
schizophrenic patients.
Methods
• Retrospective
• IRB approval obtained prior to study
commencement
• Data collected over a one year period from
April 2012 to April 2013
• Information obtained from EMR
Methods
•
•
•
•
Inclusion criteria:
Diagnosis of Schizophrenia
Treated in outpatient setting
At least one hemoglobin A1c obtained
within the study period
Methods
•
•
•
•
Exclusion criteria:
End stage renal disease
Hemolytic anemia/ hemoglobinopathy
No hemoglobin A1c within study period
• 245 Schizophrenic patients identified.
• Of these, 72 had diagnosis of Diabetes
mellitus.
• 7 were excluded due to lack of A1c during
the study period.
• Total of 65 patients included
• A control cohort of 65 randomly sampled
diabetic patients was recruited based on
the matching variables of age, race, and
gender.
Variables
 Age
 Gender
 Race
 BMI
 LDL level
 Triglyceride level
 Smoking status
 Number of clinic visits
• Use of atypical
medications
• Use of Insulin therapy
Variable
Schizophrenic
Nonschizophrenic
p-value
Mean Age
56.46
56.02
0.81
Gender
M 28
F 37
M 30
F 35
Race
Caucasian 36
AA 22
Hisp 6
Caucasian 38
AA 22
Hisp 5
0.
A1c
6.645
8.409
0.00
Number of
Clinic visits
4.6
4.83
0.71
Smoking
Y 29
N 36
Y 20
N 45
0.
Kidney
Disease
Y 10
N 55
Y 10
N 55
0.
Variable
Schizophren Nonschizop
ic
hrenic
P-value
LDL
0.93
HDL
0.84
Triglycerides
0.21
Anemia
BMI
No.
Variable
P – value
1
Age
0.006
2
Gender
0.820
3
Race
0.030
4
Smoking status
0.306
5
Anemia
0.516
6
Number of clinic visits
0.457
7
BMI
0.272
8
Schizophrenia
0.000
Limitations of Study
• Retrospective
• Chart based
• Multiple providers
Conclusions
1. There was a significant difference in the
hemoglobin A1c between patients with
schizophrenia {mean A1c 6.6, SD =1.3} and
without schizophrenia {mean A1c 8.4, SD =2.6}
after controlling the effect of age, race, gender,
BMI, anemia and number of clinic visits (p
<0.001).
Conclusions
2. There was a significant difference in the
prevalence of vascular diseases between
patients with schizophrenia {9.2%} and
without schizophrenia {33.8%} after
controlling the effect of age, race, gender,
BMI, anemia and number of clinic visits (p
<0.001).
Conclusions
3. There was no significant difference in the
hemoglobin A1c between schizophrenic
patients taking atypical antipsychotics {mean
A1c 6.4, SD =1.1} and patients taking typical
antipsychotics{ mean A1c =6.9, SD = 1.6}
(p<0.060).
Conclusion
• A diagnosis of schizophrenia does not
mean that a patient is incapable of
managing their medical conditions.
• Caretakers must be careful to avoid letting
bias influence their decision – making.
• Further prospective study may uncover
reasons for this difference.
Acknowledgements
• Srikrishna Varun Malayala, MBBS
• Khalid J Qazi, MD, MACP
• Nikhil Satchidanand, PhD
• Thank You