Antipsychotics (Mood Stablizers & Antidepressants*) Cardiometabolic *Despite less available evidence, similar principles apply to these medication classes

Lifestyle Blood Glucose Smoking Diet Activity

Lifestyle Intervention (Diet, Physical Activity and Smoking Cessation); Refer for assessment and intervention by appropriate health professional if necessary

Monitor for: Pre-Diabetes: Metabolic Weight gain HbA1C 6-6.4% Rapid early weight gain F. Glu 6.1- 6.9 mmol/L Syndrome or >= 7% from baseline > 140/90 mm Hg Estimate 10-year Poor Physical Diabetes*: Any 3 of: BMI (kg/m2) (over repeated CV risk using an Waist Circum: HbA1C ≥ 6.5% Smoker Diet Inactivity 25 -29: Overweight measurements) established tool ≥ 88 cm women > 30: Obese F. Glu ≥ 7 mmol/L ≥102 cm men Waist Circum: Rand. ≥ 11.1 mmol/L F.Trig: ≥1.7 mmol/L ≥ 88 cm women F. HDL: ≥102 cm men *2 tests, dierent days < 1 mmol/L men < 1.2 women F.Gluc: ≥ 5.6 mmol/L BP: ≥ 130/85 mmHg A1C >=5.7 % Smoking cessation Eliminate sugary Walking is safe; aim Screen for eating disorder, Lower threshold sleep apnea, and NAFLD Sodium reduction Pre-diabetes: Interventions are based for some groups counseling and drinks & processed for 10,000 steps/day. ZONE DANGER Increased frequency of glucose on 10-year calculated mmol/L pharmacotherapy snack foods Progress as appropriate Reduce daily intake by See 2012 Canadian or medication Rx monitoring CV risk to moderate (sweating, 500-1000 kcal/day Hypertension Consider metformin Monitor changes in Increase consumption able to talk) to vigorous Cognitive behavioural therapy Program See 2012 update of the mental status/ of fruits, vegetables, (increased sweating, recommendations for Diabetes: Canadian Cardiovascular Consider bariatric surgery for di culty talking) the management of HbA1C q3months Society guidelines for the medication e cacy & bre BMI >= 40 kg/m2 or and side-eects activity hypertension: BP Refer to Diabetes Education Program diagnosis and treatment >= 35 with comorbid disease of dyslipidemia for the (e.g. olanzapine and 3 meals/day including measurement, diag- See Canadian Diabetes Association Treat individual See 2006 Canadian Clinical prevention of cardio- clozapine) breakfast, refer to Consider medical nosis, assessment 2013 Clinical Practice Guidelines for factors using clearance for those Practice Guidelines on the of risk and therapy. the Prevention and Management of vascular disease in the relevant guidelines dietitian if available. adult. Can J Cardiol at risk Management and Prevention Can J Cardiol Diabetes in Canada. Can J Diabetes smoke-free.ca of Obesity in Adults and 29(2):151-167 28(3):270-287 2013;37 (suppl 1):S1-S212. knowledge.camh.net eatrightontario.ca csep.ca Children [CMAJ 176(8): S1-13 INTERVENTION

150 minutes of activity/ Non-fasting For Most: HbA1C <6.5-7 % week In increments of BMI of HDL 2.6 mmol/l Treat to individual at least 10 min. <140/90 mmHg reecting tighter 18.5 – 24.9 kg/m2 BMI, BP, glucose, Aerobic: for the rst Smoking Balanced Refer to Framingham and targets Moderate to vigorous Diabetes/CKD/ 5 years Cessation Diet activity Waist circumference and Reynolds Risk Global CV Risk CV Disease: values: http://cvdrisk Resistance: in healthy range Fasting glucose Management Muscle-strengthening <130/80 mmHg checksecure.com/ exercises 4-5.9 mmol/L Default.aspx TARGET

FPG= Fasting Plasma Glucose; RPG = Random Plasma Glucose; BMI = Body Mass Index; Total Chol = total cholesterol; LDL = Low Density Lipoprotein; HDL = High Density Lipoprotein; BP= Blood pressure Monitoring: How Often and What to Do Applies to patients prescribed antipsychotics and metabolically active mood stabilizers and antidepressants Frequency: As a minimum review those prescribed a new agent at baseline and at least once after 3 months. Weight should be assessed monthly in the first 3 months of taking a new antipsychotic as rapid early weight gain may predict severe weight gain in the longer term. Subsequent review should take place annually unless an abnormality of physical health emerges, which should then prompt appropriate action and/or continuing review at least every 3 months. DON’T JUST

Baseline 4 weeks 8 weeks 12 weeks Quarterly Annually History: SCREEN: Ask about Personal/FHx X X family history (diabetes, INTERVENE! Lifestyle Review X X X X X X obesity, CVD in rst degree Weight/WC X X X X X X relatives <60 yrs), gestational FOR ALL PATIENTS IN THE BP X X X diabetes. DANGER ZONE Note ethnicity. X FPG/HbA1C X X The primary care provider and psychiatrist Lipid Prole X X X will work together to ensure appropriate monitoring and interventions are provided Smoking, diet, and physical activity If fasting lipid pro le cannot be obtained, a non-fasting sample is satisfactory and communicated to avoid over or under Derived from consensus guidelines 2004, j clin. psych 65:2 monitoring. The primary care provider will usually lead on supervising the provision of Investigations physical health interventions. The psychiatrist Fasting estimates of plasma glucose (FPG), HbA1c, and lipids (total Specic Adjunctive Pharmalogical will usually lead on decisions to signi cantly cholesterol, non-HDL, HDL, triglycerides). If fasting samples are Interventions change antipsychotic medicines. impractical, then non-fasting samples are satisfactory for most For mitigation of excess weight gain associated with measurements except for LDL and triglycerides. antipsychotic use, the strongest evidence is for off-label use of Metformin and Topiramate (Mayan, 2010). Consider Metformin first due to better Review of Antipsychotic Medication tolerability pro le unless there is a co-morbid binge- eating disorder (McElroy, SI, 2009). Please be advised Choose lower metabolic liability medication rst-line when possible. that o-label use requires documented informed Response in rst episode psychosis is robust independent of agent. consent. Discontinue if no sign of efficacy (continuing Changing or discontinuing antipsychotic requires careful clinical weight gain if used for weight loss or stabilization) judgment, balancing metabolic bene ts against relapse risk. after 3 months at therapeutic dose. Ideally psychiatrist supervised. Should be a priority if there is: • Rapid weight gain (e.g. 5kg <3 months) following Metformin: Weight Gain & Primary Prevention of antipsychotic initiation. Diabetes : Start 250 mg po BID, titrate every 1-2 weeks as • Rapid development (<3 months) of abnormal lipids, BP, or glucose. clinically indicated and tolerated. Dose range is 750 mg - 2 Gm/day The psychiatrist should consider whether the antipsychotic drug regimen has played a causative role in these Caution with renal or hepatic impairment. Avoid excessive abnormalities and, if so, whether an alternative regimen could be alcohol use. Monitor for GI side effects. Monitor for B12 de ciency. expected to oer less adverse eect: Topiramate: If clinical judgment and patient preference support Weight Gain: Start 12.5 mg po BID; titrate by 25-50 mg per day With thanks to the On Track FEP program continuing with the same treatment then ensure appropriate further in divided doses every 1-2 weeks as tolerated to a maximum of for their monitoring and clinical considerations. 100 mg po BID. Adapted for use by the Avoid antipsychotic polypharmacy when possible; Avoid o-label Caution with renal or hepatic impairment. Avoid excessive Ontario Metabolic Task . use of antipsychotics. alcohol use. Monitor for cognitive changes. Parasthesias are With permission from Curtis J, Newall H, common but generally well-tolerated. Samaras K. © HETI 2011; Shiers, D et al