Det metaboliske Syndrom Hvad er risikoen hos patienter? Hvad gør NIP skizofreni på området?

Transcription

1 Det metaboliske Syndrom Hvad er risikoen hos patienter? Hvad gør NIP skizofreni på området? Henrik Lublin Centerchef, dr.med. Psykiatrisk Center Glostrup

2 Increased Mortality Rates for Medical Disorders in Mental Illness Increased risk of death from medical causes in schizophrenia, 1 and 20-30% = years shorter life expectancy 2,3.. SMR 2-3. Bipolar and unipolar affective disorders also associated with higher SMRs from medical causes males/2.1 females in bipolar disorder 1.5 males/1.6 females in unipolar disorder SMR = standardized mortality ratio (observed/expected deaths) 1. Harris EC et al. Br J Psychiatry. 1998;173: Newman SC, Bland RC. Can J Psychiatry. 1991;36: Newcomer J, Hennekens CH. JAMA 2007; 298: Ösby U et al. Arch Gen Psychiatry. 2001;58: Modified from John Newcomer 2009

3 Total YPLL by Primary Cause for Public Mental Health Patients with Mental Illness Combined data for schizophrenia and schizoaffective disorder from 5 US states (MO, OK, RI, TX and UT) from 1997 to 2001 Primary cause of death Heart disease Cancer Suicide Accidents, including vehicles Chronic respiratory Diabetes Pneumonia/influenza Cerebrovascular disease All causes of death* Total YPLL (Person-years lost) 14, , , , , , , , ,812.2 Deaths (n) ,829 YPLL = years of potential life lost Unpublished results courtesy of CW Colton Modified from John Newcomer 2009 *Note: Includes deaths from causes not listed

4 Metabolic syndrome NCEP ATP III Waist Male 102 cm Female 88 cm TG 150 mg/dl (1,69 mmol/l) HDL <40 mg/dl (1.04 mmol/l) <50 mg/dl (1.29 mmol/l) Hypertension Fasting glycaemia 130/85 mm Hg 110 mg/dl (6.1 mmol/l) 3 criteria = MS National Cholesterol Education Program Adult Treatment Panel III

5 Rates of Metabolic syndrome Study NCEP (Ford et al, 2004) US general population study CATIE (McEvoy et al, 2005) US, Schizophrenia Basu et al, 2004 US, Schizoaffective Kato et al, 2004 US, Schizophrenia Hagg et al, 2006 Sweden, Schizophrenia Heiskanen et al, 2003 Finland, Chronic Schizophrenia Cohn et al, 2004 Canada, Sz & Schizoaffective Pts Rate of Metabolic Syndrome 27% 41% 42% 63% in all patients 41% in non-hispanic patients, 74% in Hispanic patients, 70% in Cuban Americans and 88% in other Hispanic subgroups Currently untreated 17% (M=7% F= 50%) Cloz 48% Olz 39% other SGA 33% Typ 38% 37% 42.6% of men and 48.5% of women

6 Comparison of Metabolic Syndrome Prevalence in Fasting CATIE Subjects vs Matched NHANES III Controls Males Females CATIE NHANES P CATIE NHANES P N = 509 N = 509 N = 180 N = 180 Metabolic Syndrome Prevalence 36.0% 19.7% % 25.1%.0001 Waist Circumference Criterion 35.5% 24.8% % 57.0%.0001 Triglyceride Criterion 50.7% 32.1% % 19.6%.0001 HDL Criterion 48.9% 31.9% % 36.3%.0001 BP Criterion 47.2% 31.1% % 26.8%.0001 Glucose Criterion 14.1% 14.2% % 11.2%.0075 McEvoy JP, et al. Schizophr Res. 2005;80: National Health and Nutrition Examination Survey (NHANES III)

7 Cardiovascular Risk Factors The Framingham Study Multiple Risk Factors 5 Odds ratios Single Risk Factors BMI >27 Smoking TC >220 HTN Wilson PWF et al 1998 BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension. DM Smoking + BMI Smoking + BMI + TC >220 Smoking + BMI + TC >220 + DM Smoking + BMI + TC >220 + DM + HTN

8 Reasons for Increased CVD Mortality in Major Mental Disorders Primary and secondary prevention limitations for mentally ill versus general population Less likely to be screened or treated for dyslipidemia, hyperglycemia, hypertension Less likely to receive angioplasty or coronary artery bypass grafting Less likely to receive drug therapies of proven benefit (thrombolytics, aspirin, beta-blockers, ACE inhibitors) More likely to have premature mortality post-myocardial infarction Newcomer J Hennekens CH. JAMA 2007; 298(15): Druss BG et al. Arch Gen Psychiatry. 2001;58:

9 Prevention Opportunities Missed: Low Rates of Treatment for Metabolic Disorders In Schizophrenia in CATIE Percentage of Patients N=1460 Diabetes HTN Dyslipidemia Nasrallah H et al. Schizophrenia Research 2006; 86:15 22

10 Reasons for Increased CVD Mortality in Major Mental Disorders Modifiable health risk factors Lipid abnormalities (TC, LDL-C, TG, HDL) Diabetes Hypertension Metabolic syndrome Physical inactivity Smoking Drug treatment Access to and/or utilization of medical care Adherence with therapies Economic capabilities Newcomer J Hennekens CH. JAMA 2007; 298(15):

11 Ten most debilitating side effects Angermeyer and Matschinger, 1999

12 Weight Change After 10 Weeks Standard Drug Doses, Estimates From a Random Effects Model Weight change (kg) Modified after Allison et al Am J Psychiatry 1999;156:

13 Weight Change as a Function of Drug % of Subjects No change or lost weight 7% weight gain > 7% weight gain Clz Olz Ris Ser Hal Zip Ari Que Modified after Lublin et al 2005

14 Adiposity and Medical Diseases Relative Risk Type 2 DM Cholelithiasis Relative Risk Hypertension Coronary heart disease Body Mass Index Female Willett WC et al. N Engl J Med 1999; 341: Body Mass Index Male

15 Physical activity levels, exercise and sedation Schizophrenics take little exercise 1,2 Factors: illness (negative symptoms, depression) sedative medication lack of opportunity for exercise general motivation Exercise: reduces relative risk of atherosclerosis improves lipid profiles, improves glucose tolerance reduces risk of obesity and hypertension 1 Brown et al, 1998; 2 McCreadie 2003; Connelly & Kelly 2005

16 Poor Diet Schizophrenics have been shown to consume a poor diet: high fat, low fibre 1 <50% recommended fruit & vegetable intake, poor in vitamins (especially folate) 2 interventions previously focused on individual supplements (e.g., omega-3 fats) rather than total intake and balance 3 1 McCreadie 1998; 2 McCreadie 2003; 3 Joy et al, 2003

17 Life Expectancy Increases With Weight Loss Among Obese Diabetic Patients Life expectancy (years) 18 95% confidence interval Weight loss (kg) in first 12 months Lean et al. Diabet Med 1990;7:228 33

18 Consensus Development Conference ADA/APA Monitoring Protocol for Patients Atypical Antipsychotics

19 General recommendations for the use of antipsychotics Consider metabolic and CVD risk when commencing AP treatment Education of patient, family, caregivers in diet and exercise Baseline screening Regular monitoring Choice of drug Referral to specialized services when appropriate

20 NIP-indikatorer MS Indikator: 6. Andel patienter, som har haft vægtøgning som konsekvens af antipsykotisk behandling. Standard: Ikke fastsat %

21 NIP-indikatorer MS Indikator: 8. Andel af patienter, som har forhøjet BMI ( 30 kg kg/m 2 ). Standard: Ikke fastsat %

22 NIP-indikatorer MS Indikator: 9. Andel af patienter, som har forøget taljemål (K: >88 cm; M: >102 cm) Standard: Ikke fastsat

23 NIP-indikatorer MS Indikator: 10. Andel af patienter, som har forhøjet BS (fastende > 6,1 mm, ikke-fastende > 11,1 mm) Standard: Ikke fastsat

24 NIP-indikatorer MS Indikator: 11. Andel af patienter, som har forhøjede lipidværdier (Forhøjede triglycerider: 1,69 mmol. Forhøjet HDL-kolesterol: Mænd < 1,03 mmol/l, kvinder < 1,29 mmol) Standard: Ikke fastsat

25 NIP-indikatorer MS Indikator: 12. Andel af patienter, som har forhøjet BT (Forhøjet blodtryk: 130/85 mm Hg) Standard: Ikke fastsat

26 Tak