clinical practice guideline title: metabolic monitoring in ... monitoring in adult mental... ·...

CLINICAL PRACTICE GUIDELINE: Metabolic Monitoring in Adult Mental Health and Substance Use Services

AUTHORIZATION:

MHSU Quality Performance Committee Date Released:

April 11/11 of 12

Author(s): Fraser Health CDST# :

NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.

1.0. PURPOSE

To provide a framework for the multidisciplinary team-based approach to metabolic monitoring (i.e., screening, assessment, intervention, and monitoring and maintenance of metabolic risk factors) in adult Mental Health and Substance Use (MHSU) services.

2.0. SCOPE

These guidelines apply to all adult Mental Health and Substance Use Services (MHSU) clients. Special considerations, which are not included in these guidelines, must be undertaken for monitoring individuals under the age of 18, geriatric clients, and individuals who are pregnant.1 This monitoring does not supersede specific monitoring requirements for other psychotropic drugs (e.g., clozapine). These guidelines pertain to all psychotropic drugs, not solely antipsychotics or second-generation antipsychotics (SGAs).

3.0. RATIONALE

Metabolic syndrome Metabolic syndrome (MetS) is a term used to describe a group of cardiometabolic risk factors or conditions that put people at a higher risk of developing heart disease, stroke and diabetes. Those conditions include: abdominal obesity (i.e., excessive fat tissue in and around the abdomen and waist); atherogenic dyslipidemia (i.e., blood fat/cholesterol disorders that promote plaque buildups in artery walls); hypertension (i.e., elevated blood pressure); insulin resistance or glucose intolerance (i.e., the body cannot properly use insulin or blood sugar); prothrombotic state (i.e., elevated factors in the blood which causes blood to clot more easily); and proinflammatory state (i.e., increased inflammation). Compared to the general population, individuals with metabolic syndrome are three times as likely to have, and are twice as likely to die from, a heart attack or stroke. They also have up to a nine-fold greater risk of developing type 2 diabetes.1,5

Metabolic syndrome and mental health and substance use Serious mental illness is associated with a significant excess of physical co-morbidity and mortality in comparison to the general population. The life span of individuals with serious mental illness is estimated to be 25 to 30-years shorter than that of general population, due primarily to cardiovascular disease. The prevalence of metabolic syndrome and diabetes in this population may be increased by both lifestyle factors present in the MHSU population as well as psychotropic medication treatment.7 A number of factors contribute to the Mental Health and Substance Use population being at greater risk of developing metabolic syndrome:

Serious mental illness is a significant risk factor for the development of metabolic syndrome and a number of chronic diseases including cardiovascular disease and diabetes.9,26 Schizophrenia is recognized by the Canadian Diabetes Association as an independent risk factor for diabetes.26

Living in poverty, food security and lifestyle factors that are a consequence of the negative symptoms of the illness put individuals at higher risk.


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Psychotropic medication treatment is associated with metabolic side effects. The majority of concern has involved second-generation (atypical) antipsychotics. People who start antipsychotic agents can experience changes in both weight and metabolic indicators (e.g., weight gain, lipids, fasting glucose) within a period of a few months. Emerging evidence shows that other categories of psychotropic medications have been found to have similar relationships.3,5,10,17,18,20,21,23

There is potential for metabolic changes as a result of polypharmacy (i.e., the use of more than one drug simultaneously).

Alcohol-dependent individuals also have a high and disproportionate level of cardiovascular disease risk. Heavy alcohol drinking is associated with higher glucose levels and hypertension, therefore increasing the risk of related conditions such as diabetes, obesity, metabolic syndrome, and atherosclerosis.14,22

The mental and physical health and well-being of individuals are deeply interconnected. Some of the biological features of mental illness increase metabolic risk, and chronic physical illness can also exacerbate mental illness presentation.11,24

Metabolic monitoring Although medical treatment is beyond the scope of MHSU services, the increased risk of serious health conditions in MHSU patients, residents and clients (hereafter referred to as clients) necessitates the need for routine health screening and metabolic monitoring, particularly as individuals start psychotropic medications.3 A holistic approach to MHSU services, which recognizes the interconnectedness of physical and mental health will also result in improved rehabilitation outcomes. Prevention services, health screening and the coordination of appropriate and regular access to primary health care should therefore be an integral component of MHSU programs in order to reduce morbidity and mortality. Increased coordination, collaboration and collaborative/shared care between health care sectors will increase the capacity of each sector and will improve health care outcomes for people with mental illness and chronic diseases.4,9,10,11,19,24,25

4.0. UNDERLYING PRINCIPLES

1. The physical health of MHSU clients is a necessary and important element of MHSU services and metabolic monitoring is the responsibility of all staff.

2. Given the rationale above, these metabolic monitoring guidelines incorporate both special monitoring requirements for clients on psychotropic medications as well as routine health screening guidelines.

3. Metabolic and general health monitoring extends between MHSU and primary health services. Metabolic monitoring is a service that is integrated with primary health services and all staff are expected to collaborate with the client’s primary health team to achieve the expected outcomes.

4. Given the multidisciplinary nature of our services, metabolic monitoring is an MHSU service provided by a team. The Primary Physician/Psychiatrist is responsible for the overall management and oversight of the client’s metabolic monitoring. MHSU Clinicians are responsible for supporting the Primary Physician/Psychiatrist as part of a multidisciplinary MHSU team, by completing metabolic monitoring tasks when within the Clinician’s scope of practice and role description.

5. These guidelines outline the MHSU definition of metabolic monitoring and provided recommended monitoring frequencies based on risk level, but do not prescribe how the guidelines are put into practice. Each team has the ability to design a process that is functional within their resources.


AUTHORIZATION:


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5.0. GUIDELINES FOR METABOLIC MONITORING

1. Metabolic monitoring is explained and offered to MHSU clients. 1.1. In alignment with a recovery-oriented model of care, clients are encouraged to take ownership of

their own metabolic monitoring as much as possible, and are supported in doing so. This includes clients being informed and having decision-making capability (i.e., medication risk-benefit).

2. Metabolic monitoring is provided collaboratively with the client’s primary care provider.

2.1. A client may have both an MHSU Most Responsible Physician/Provider (MRP), such as a Psychiatrist or GPP, as well as a primary care MRP, such as Family Physician or Nurse Practitioner. The primary care provider is a client’s overall coordinator of care, and is responsible for managing the client’s physical care, and the primary health care setting is ideal for metabolic monitoring.

2.2. The primary care provider is offered the opportunity to manage the client’s metabolic monitoring. Such a transfer of responsibility requires agreement to, delegation of, and documented confirmation of the transfer/delegation.

2.3. All monitoring information is shared between MHSU services and the client’s primary care provider. 3. Metabolic monitoring is provided based on the minimum metabolic monitoring recommendations provided

in these guidelines, and based on the Psychiatrist/Physician’s overall assessment of risk. 3.1. All clients with new antipsychotic medication starts are considered high risk.

4. At all stages of metabolic monitoring, Clinicians and Psychiatrists/Physicians:

i. develop, in collaboration with the client, a healthy lifestyle action plan; ii. assess the client for appropriate healthy lifestyle education and/or services; and iii. provide the client with or refer to the client to appropriate healthy lifestyle education and/or review the

client’s participation in education for opportunities to be enhanced; and iv. document this information either on the metabolic monitoring form (pg. 2), healthy lifestyle action plan

form or in the progress notes. 5. Clinicians and Psychiatrists/Physicians document and track the client’s metabolic monitoring information

using the metabolic monitoring and healthy lifestyle action plan forms (optional), which are kept in the client’s chart. 5.1. If at any point, Clinicians or Psychiatrists/Physicians are unable to retrieve any metabolic monitoring

information from the client, they flag the client’s file for follow-up at the next opportunity, look for alternative methods to collect that information (e.g., collect from Family Physician’s office or another source), and document it.

6. In order to ensure long-term monitoring and maintenance, all metabolic monitoring information follows a

client throughout their continuum of care, both within and outside of MHSU. 6.1. Upon discharge from an MHSU program and/or transfer to another program (either internal or

external to MHSU Services), all metabolic monitoring information is both sent to the new program (i.e., included in referral and/or transfer package) and carbon copied (CC’d) to the client’s Family Physician or primary care provider.

7. MHSU program / site teams utilize a reminder or flagging system to make Clinicians and

Psychiatrists/Physicians aware of individual clients’ metabolic monitoring requirements and timelines.


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6.0. DEFINITIONS

Changes in psychotropic medications: For the purpose of these guidelines, changes in psychotropic medications is defined as significant changes in dose (increase in dose [proportional to baseline] or change in medications). Client: The term ‘client’ is used to represent clients, patients and residents of Fraser Health. Clinician: A Clinician is any member of the client’s care team who is involved in their metabolic monitoring and who has been assigned or delegated metabolic monitoring tasks. Metabolic monitoring, and health care in general, employs an integrated, interdisciplinary team-based approach. Therefore, the client’s care team may include both regulated and unregulated health care professionals, all of which are referred to as Clinicians for the purposes of these guidelines (e.g., Physicians, Case Managers [RN, RPN, Social Work, Clinical Counselor, other], Health Care Workers, Rehabilitation and Recovery Workers [Physical Therapist, Occupational Therapist, Recreation Therapist, other]). The Clinician is responsible for supporting the Primary Physician/Psychiatrist as part of a multidisciplinary MHSU team, by completing metabolic monitoring tasks when within the Clinician’s scope of practice and role description. Metabolic syndrome (MetS): Metabolic syndrome is a grouping of cardiometabolic risk factors implicated in the development of premature cardiovascular disease and type 2 diabetes mellitus. Clinical diagnosis of metabolic syndrome is made when any three of the following five risk factors are present:

1. elevated waist circumference; 2. elevated blood pressure, or antihypertensive drug treatment in a patient with a history of hypertension; 3. elevated triglycerides, or drug treatment for elevated triglycerides; 4. reduced high-density lipoprotein cholesterol (HDL-C), or drug treatment for reduced HDL-C); and 5. elevated fasting glucose, or drug treatment of elevated glucose.2

Metabolic monitoring: The screening and assessment of metabolic risk factors; the prevention and intervention of risk factors to manage existing metabolic conditions and to prevent the escalation into metabolic syndrome and/or other medical conditions such as diabetes and cardiovascular disease; and long-term monitoring and maintenance. Primary care provider: Primary care providers are the coordinators of primary health care service. With respect to metabolic monitoring, the Family Physician (FP) or primary care provider (e.g., Nurse Practitioner) is responsible for the provision of medical care, which is out of the sphere of responsibility for MHSU and Psychiatry services. The primary care provider can be the Family Physicians or another member of the Family Physician’s broader professional team, which could include nurse practitioners, public health staff, community nurses, midwives, pharmacists, home and community care workers, dietitians, specialists, and many other health professionals and non-governmental organizations who work as a team with patients and their extended families. Primary Physician/Psychiatrist: The client’s most responsible physician (Psychiatrist, Family Physician, GPP, Nurse Practitioner, or other) who is responsible for the client’s metabolic monitoring within Fraser Health Mental Health and Substance Use (e.g., by virtue of having prescribed psychotropic medication). The Primary Physician/Psychiatrist is responsible for the overall management and oversight of the client’s metabolic monitoring.


AUTHORIZATION:


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Psychotropic medications: Drugs that affect the mind/perception, behavior and mood. Common categories of psychotropic drugs include antidepressants, anxiolytics or anti-anxiety agents, antipsychotics, and mood stabilizers. Second-generation (atypical) antipsychotics (SGAs): Medicines that treat the symptoms of schizophrenia. Examples include -- generic name (brand name): olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperidal, Risperidal Consta), ziprasidone (Zeldox). They are sometimes called atypical or newer antipsychotics. Because they may be better tolerated, second-generation antipsychotics are often used as first-line treatment for those newly diagnosed with schizophrenia.13

7.0. SUPPORTING DOCUMENTATION

Clinicians and Psychiatrists/Physicians will document and track the client’s metabolic monitoring data using the: metabolic monitoring form, to perform an initial risk assessment and to monitor risk factors over time; and (optional) healthy lifestyle action plan, to develop healthy lifestyle modification action plans with clients and

to monitor progress over time in order to inform appropriate resources and referrals.

8.0. ADDITIONAL RESOURCES

Appendix A - Criteria for clinical diagnosis of Metabolic Syndrome and other risk factors Appendix B - Risk levels and recommended monitoring frequencies Process algorithm Clinical algorithm Medication information resources handout BC Mental Health and Addiction Services recommended lab monitoring frequency for atypical

antipsychotics and mood stabilizers: www.bcmhas.ca > Pharmacy > Lab monitoring for medications: http://www.bcmhas.ca/Pharmacy/Lab_monitoring/default.htm

Intranet: http://fhpulse/clinical_programs/mental_health_and_addictions/resources/Pages/TakingWellnesstoHeart.aspx Client brochures: Various topics - Available in Print Shop and on intranet site Staff information resource: Glossary - Available in Print Shop and on intranet site

9.0. REFERENCES

1. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2007; 176 (8 Suppl): Online 1 -117.

2. Alberti KGMM et al. Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120;1640-1645.

3. Attux C, Quintana MI, Chaves AC. Weight gain, dyslipidemia and altered parameters for metabolic syndrome on first episode psychotic patients after six-month follow-up. Revista Brasileira De Psiquiatria 2007; 29: 346-349.

4. Barnes TRE, Paton C, Hancock E, Cavanagh MR, Taylor D, Lelliot P. Screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics: A quality improvement programme. Acta Psychiatrica Scandinavica 2008; 118: 26-30.

http://www.bcmhas.ca/Pharmacy/Lab_monitoring/default.htm

http://fhpulse/clinical_programs/mental_health_and_addictions/resources/Pages/TakingWellnesstoHeart.aspx


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5. Bobes J, Arango C, Aranda P, Carmena R, Garcia-Garcia m. Rejas J. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: Results of the CLAMORS Study. Schizophrenia Research 2007; 90:162-173.

6. British Columbia Guidelines and Protocols Advisory Committee. Guidelines for Cardiovascular Disease – Primary Prevention (2010), Diabetes Care (2010), Hypertension – Detection, Diagnosis and Management (2008), Overweight, Obesity and Physical Inactivity (2008). www.bcguidelines.ca/gpac/.

7. Brown S. Excess mortality of schizophrenia: a meta-analysis. Br J Psychiatry 1997; 171:502-8 In Cohn TA, Sernyak MJ. Metabolic Monitoring for Patients Treated With Antipsychotic Medications. Can J Psychiatry 2006; 51:492-501.

8. Canadian Diabetes Association. www.diabetes.ca. Downloaded June 2010.

9. Canadian Mental Health Association, Ontario. Diabetes and Serious Mental Illness: Future Directions for Ontario. March 30, 2009.

10. Cohn TA, Sernyak MJ. Metabolic Monitoring for Patients Treated With Antipsychotic Medications. Can J Psychiatry 2006; 51:492-501.

11. Fischel MA, Watson GS, Montine TJ, Wang Q, Green PS, Kulstad JJ, Cook DG, Peskind ER, Baker LD, Goldgaber D, Nie W, Asthana S, Plymate SR, Schwartz MW, Craft S. Hyperinsulinemia Provokes Synchronous Increases in Central

Inflammation and -Amyloid in Normal Adults. Archives of Neurology. 2005;62:1539-1544.

12. Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 2003.

13. HealthLinkBC. Second-generation antipsychotics for treating schizophrenia. June 2010. http://www.healthlinkbc.ca/kb/content/drugdetail/aa47298.html.

14. Jarvis CM, Hayman LL, Braun LT, Schwertz DW, Estwing Ferrans C, Piano MR. Cardiovascular Risk Factors and Metabolic Syndrome in Alcohol- and Nicotine-Dependent Men and Women. Journal of Cardiovascular Nursing. 2007; 22(6): 429-435.

15. Makin P, Bishop DR, Watkinson HMO. A prospective study of monitoring practices for metabolic disease in antipsychotic-treated community psychiatric patients. BMC Psychiatry 2007; 7(28).

16. Marder SR et al. Physical Health Monitoring of Patients with Schizophrenia. Am J Psychiatry 2004; 161:1334–1349.

17. McEvoy JB, Meyer JM, Goff DC. Schizophrenia Research 2005; 80:19-32.

18. McIntosh D, Kjernisted K, Hammond J. Diabetes and Depression: What is the Association Between These Common, Chronic Illnesses? Can Diabetes. 2008:3-7.

19. Newcomer JW. Metabolic Syndrome and Mental Illness. Am J Manag Care. 2007.13:S170-S17.

20. Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005; 19(Suppl 1):1-93 In Cohn TA, Sernyak MJ. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006; 51:492-501.

21. Newcomer JW, Haupt DW. The metabolic effects of antipsychotic medications. Can J Psychiatry. 2006; 51(8):480-491.

22. O’Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol 50: 1009-1014.

23. Taylor V et al. Adults with mood disorders have an increased risk profile for cardiovascular disease within the first 2 years of treatment. Can J Psychiatry 2010; 55(6):362-368.

24. Thakore JH, Mann JN, Vlahos I, Martin A, Reznek R. Increased visceral fat distribution in drug-naive and drug-free patients with schizophrenia. International Journal of Obesity (2002) 26, 137–141.

25. Waterreus AJ, Laugharne JDE. Screening for the metabolic syndrome in patient’s receiving antipsychotic treatment: a proposed algorithm. MJA 2009; 190(4):185-189.

26. Woo V, Harris SB and Houlden RL. Canadian Diabetes Association Position Paper: Antipsychotic Medications and Associated Risk of Weight Gain and Diabetes. Can J Diabetes 2005; 29(2):111-112.

27. World Health Organization. (2000). Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation on Obesity. Geneva: WHO.


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APPENDIX A – RISK FACTORS

Table 1 - Criteria for clinical diagnosis of Metabolic Syndrome

Clinical diagnosis of metabolic syndrome = Any three (3) or more of five risk factors are present:

Risk factor Defining level Related medical condition

Elevated waist circumference

a,b

Male: Female:

≥ 102 cm (40 inches)

≥ 88 cm (35 inches)

Abdominal obesity

Elevated blood pressure If no co-morbid conditions: > 140/90 Hypertension

If self measured: > 135/85

If client has diabetes, renal disease or other target organ damage

c: > 130/80

or drug treatment for hypertension (antihypertensive)

Elevated triglycerides

> 1.7 mmol/L High cholesterol / Dyslipidemia

or drug treatment for elevated triglycerides d

Reduced high-density lipoprotein cholesterol (HDL-C)

Male:

Female: < 1.03 mmol/L

< 1.29 mmol/L

High cholesterol / Dyslipidemia

or drug treatment for reduced HDL-C d

Elevated fasting glucose e

≥ 5.6 mmol/L or drug treatment for elevated glucose Diabetes

Notes: a If waist circumference is difficult to obtain, abdominal obesity may be ‘eye-balled’ or if BMI is ≥ 30 kg/m

2, it can be initially assumed.

b The Health Canada defining levels for waist circumference are recommended for use with all Canadian adults (except for pregnant and lactating women) and are used in these guidelines. However, data used to support the cut-offs were derived predominantly from studies in Caucasian populations. There is evidence that certain ethnic or racial groups may differ from Caucasians in their levels of total body fat at a given BMI, in their fat distribution patterns, and in their degree of health risk. Differences may be influenced in part, by differences in body build or body proportions. Population-based values for waist circumference are provided below for information purposes only. The ethnic-specific data provided are pragmatic cut-offs and better data are required to link them to risk. Ethnicity (origin/descent) should be basis for classification, not country of residence.

Ethnic group Men Women

European ≥ 94 cm ≥ 80 cm

South Asian, Chinese (Chinese, Malay, Asian Indian) ≥ 90 cm ≥ 80 cm

Japanese ≥ 85 cm ≥ 90 cm

Ethnic South and Central American Use South Asian cut-off points until more specific data available

Sub-Saharan African Use European cut-off points until more specific data available

Eastern Mediterranean and Middle East (Arab) Use European cut-off points until more specific data available

First Nations, Inuit and other Canadian Aboriginal Use Table 1 cut-off points until more specific data available

c Target organ damage includes: cerebrovascular disease, coronary heart disease (CHD), left ventricular hypertrophy (LVH), chronic kidney disease (CKD), peripheral vascular disease and hypertensive retinopathy.

d The most commonly used drugs for elevated triglycerides and reduced HDL-C are fibrates and nicotinic acid. A patient taking one of these drugs can be presumed to have high triglycerides and low HDL-C.

e Most with type 2 diabetes mellitus will have metabolic syndrome by this criteria.

Sources:

Clinical diagnosis definition: Alberti KGMM et al. Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120;1640-1645. Risk factor defining levels: 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2007; 176 (8 Suppl): Online 1 -117.; Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 2003.; British Columbia Guidelines and Protocols Advisory Committee. Guidelines for Cardiovascular Disease – Primary Prevention (2010), Diabetes Care (2010), Hypertension – Detection, Diagnosis and Management (2008), Overweight, Obesity and Physical Inactivity (2008). www.bcguidelines.ca/gpac/.; International Chair on Cardiometabolic Risk. www.cardiometabolic-risk.org.

http://www.bcguidelines.ca/gpac/

http://www.cardiometabolic-risk.org/


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Table 2 - Vulnerabilities for metabolic risk factors

Risk factor Defining risk level or note

Personal or family history of any of: Diabetes High cholesterol Hypertension Heart disease

High-risk ethnicity f Aboriginal African Asian Hispanic South Asian

Tobacco use g Quit > 7 days ago

Quit < 7 days ago Current user

Sedentary / inactive lifestyle (sees Table 3 and 4)

< 30 minutes per day or 150 minutes per week of moderate- to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more, or no appreciable exercise

Poor diet quality / dietary habits (see Table 5)

Starting the Conversation (STC) brief dietary assessment and intervention tool - Higher summary scores (i.e., 8 – 16 points) reflect the greatest need for improvement.

Increasing weight > 5% increase from baseline

Notes: f Ethnicity (origin/descent) should be basis for classification, not country of residence.

g Consider tobacco use history in overall risk level.

Table 3 – Canadian physical activity guidelines for adults aged 18-64

Guidelines: To achieve maximum health benefits, adults aged 18-64 years should accumulate at least 150 minutes of moderate- to

vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more. It is also beneficial to add muscle and bone strengthening activities using major muscle groups, at least 2 days per

week. More physical activity provides greater health benefits.

Intensity: Moderate-intensity physical activities will cause adults to sweat a little and to breathe harder. Activities like brisk walking

or bike riding. Vigorous-intensity physical activities will cause adults to sweat and be ‘out of breath’. Activities like jogging or cross-

country skiing.

Source: Canadian Society for Exercise Physiology (2011). Canadian Physical Activity Guidelines for Adults 18-64 years. http://www.csep.ca/english/view.asp?x=804. Guidelines also available for children and adults 65+. For handout, go to: http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheets-adults-ENG.pdf

Table 4 – FITT principle overview

FF Frequency How many times a week do you participate in activities?

Physical activity should be performed each day.

II Intensity How hard do you work? Low – strolling along; Moderate – brisk walking; Vigorous –

jogging/running.

TT Time How much time do you spend on each activity?

At least 150 minutes of moderate- to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more.

2

Recommended guidelines suggest increasing time by a maximum of 10% each week.

TT Type What kinds of activities are you interested in doing?

Choose activities that you look forward to. That way, you’re more likely to continue.

Sources: 1. ActNowBC (2010). Physical activity guidelines: F.I.T.T. http://www.actnowbc.ca/everyone/physical_activity_guidelines__f.i.t.t

2. Canadian Society for Exercise Physiology (2011). Canadian Physical Activity Guidelines for Adults 18-64 years. http://www.csep.ca/english/view.asp?x=804. Guidelines also available for children and adults 65+.

http://www.csep.ca/english/view.asp?x=804

http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheets-adults-ENG.pdf

http://www.actnowbc.ca/everyone/physical_activity_guidelines__f.i.t.t

http://www.csep.ca/english/view.asp?x=804


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Table 5

Starting the Conversation brief dietary assessment and intervention tool

Add up each item score to get a summary score on a range of 0 to 16.

Lower summary scores reflect a more healthful diet and higher summary scores reflect the greatest need for improvement.

Item

Most healthful practices

(score for each answer = 0)

Less healthful practices


Least healthful practices


Over the past few months:

1. How many times a week did you eat fast food (meals or snacks)?

Less than 1 time

1 - 3 times

4 or more times

2. How many servings of fruit did you eat each day?

5 or more

3 - 4

2 or less

3. How many servings of vegetables did you eat each day?

5 or more

3 - 4

2 or less

4. How many regular sodas or glasses of sweet tea did you drink each day?

Less than 1

1 – 2

3 or more

5. How many times a week did you eat beans (like pinto or black beans), chicken or fish?

3 or more times

1 – 2 times

Less than 1 time

6. How many times a week did you eat regular snack chips or crackers (not low-fat)?

1 time or less

2 – 3 times

4 or more times

7. How many times a week did you eat desserts and other sweets (not the low-fat kind)?

1 time or less

2 – 3 times

4 or more times

8. How much margarine, butter, or meat fat do you use to season vegetables or put on potatoes, bread or corn?

Very little

Some

A lot

Summary score (sum of all items): out of 16

Source: Paxton AE et al. Starting the Conversation: Performance of a brief dietary assessment and intervention tools for health professionals. Am J

Prev Med 2001; 40(1): 67-71.


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APPENDIX B – RISK LEVELS AND RECOMMENDED MONITORING FREQUENCIES

Table 6 – Risk levels and associated recommended monitoring frequencies

Risk level Definition

High risk

Any of the following conditions are present: On psychotropic medications AND presence of any risk factors or on treatment for any risk factors; OR New start on psychotropic medications with high or moderate risk of weight gain (see Tables 7 and 8, e.g.,

atypicals/second-generation antipsychotics)

Moderate risk

Any of the following conditions are present: New start on all other psychotropic medications (those with low risk of weight gain - see Tables 7 and 8); OR On psychotropic medications but no changes in past 3 months

1; OR

Greater than or equal to 5% increase in weight seen2

Low risk No metabolic risk factors present; AND not on psychotropic medications

Risk factor Frequency of monitoring by risk level

4

High risk Moderate risk Low risk

Weight, waist circumference

BC overweight and obesity guidelines

Baseline 5

Monthly for 3 months and until stable Then 3-monthly

Baseline 5

Then 3-monthly Baseline

5

Then annually

Blood pressure

BC hypertension guidelines

Baseline 5

Monthly for 3 months and until stable Then 3-monthly

Baseline 5

Then 3-monthly

Baseline 5

Then annually

Lipids (triglycerides, HDL-C)

BC cardiovascular disease guidelines

Baseline 5

3-monthly for 6 months and until stable Then annually

Baseline 5 (if no access to results from

previous 6 months6) and:

If ≥ 5% weight increase2 or if lipids

abnormal: 6-monthly until stable, then annually

Otherwise, annually

Baseline 5

Then annually

Fasting glucose (and Hb1Ac, if physician requests)

Baseline 5

3-monthly for 6 months and until stable Then annually

If abnormal, screen/treat/refer as per BC diabetes care guidelines

and

screening algorithm

Baseline 5 (if no access to results from

previous 6 months6) and:

If ≥ 5% weight increase2: 6-monthly until

stable, then annually

If fasting glucose abnormal: Screen/treat/ refer as per as per BC diabetes care guidelines

and screening algorithm

Otherwise, annually

Baseline 5

Then annually

Diabetes-DKA checklist

3

Baseline 5

Then monthly or at every visit Baseline

5

Then 3-monthly or at every visit Baseline

5

Then annually Notes:

1. Changes in psychotropic medications = Significant increase in dose proportional to baseline or change in medications. 2. An unhealthy or risky weight gain = A rapid increase in weight (≥ 5%) over a short period of time. 3. DKA = Diabetic ketoacidosis. Please see Table 9 for the Diabetes and DKA checklist. 4. These are recommended monitoring guidelines. Ordering of monitoring is based on clinical assessment and exceptions may be

justified by clinical circumstances. The frequency of testing depends on the individual client (e.g., persistently abnormal risk factors, other disease factors) and the physician's assessment, and may be greater or less than these recommendations. Geriatric clients in particular may require more frequent monitoring.

5. Baseline is ideally at pre-treatment baseline, i.e., before or within 7 days of new medication start. 6. Previous lab work should be no older than 6 months and if there is any reason for concern about previous lab work (e.g., changes in

metabolic risk factors or in other risk factors), lab work should be repeated to establish baseline, or at any point.

http://www.bcguidelines.ca/guideline_obesity.html#management

http://www.bcguidelines.ca/guideline_obesity.html#management

http://www.bcguidelines.ca/gpac/guideline_hypertension.html

http://www.bcguidelines.ca/gpac/guideline_hypertension.html

http://www.bcguidelines.ca/gpac/guideline_cvd.html

http://www.bcguidelines.ca/gpac/guideline_cvd.html

http://www.bcguidelines.ca/gpac/guideline_diabetes.html

http://www.bcguidelines.ca/gpac/pdf/diabetes_appendix_a.pdf



http://www.bcguidelines.ca/gpac/pdf/diabetes_appendix_a.pdf


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Table 6 adapted from: - British Columbia Guidelines and Protocols Advisory Committee. Guidelines for Cardiovascular Disease – Primary Prevention (2010), Diabetes Care

(2010), Hypertension – Detection, Diagnosis and Management (2008), Overweight, Obesity and Physical Inactivity (2008). www.bcguidelines.ca/gpac/. - Woo V, Harris SB and Houlden RL. Canadian Diabetes Association Position Paper: Antipscyhotic Medications and Associated Risk of Weight Gain and

Diabetes. Can J Diabetes 2005; 29(2):111-112. - Cohn & Sernyak MJ. Metabolic Monitoring for Patients Treated With Antipsychotic Medications. Can J Psychiatry 2006; 51:492-501. - Marder SR et al. Physical Health Monitoring of Patients with Schizophrenia. Am J Psychiatry 2004; 161:1334–1349.

Table 7 – Weight gain risk of psychotropic medications

NOTE: This information was taken from the Mayo Clinic Drugs and Supplements website – please go there for the most up to date information: www.mayoclinic.com/health-information

Highest risk (+++ risk of weight gain)

Category Generic name (brand name)

Antipsychotics clozapine (Apo®, Gen®, Clozaril®) 1, olanzapine

1 (Zyprexa®)

Higher risk (++ risk of weight gain)


Antidepressants paroxetine (Paxil®), mirtazapine (Remeron®), trazodone

Tricyclic antidepressants e.g., amitriptyline, imipramine (Tofranil®), and doxepin (Sinequan®)

Monoamine oxidase inhibitors (MAOIs)

e.g., tranylcypromine (Parnate®), isocarboxazid (Marplan®) and phenelzine (Nardil®)

Antipsychotics * Higher risk when combined with a mood

stabilizer

quetiapine (Seroquel®), risperidone (Risperdal®, Risperdal Consta®)

Mood stabilizers lithium (Eskalith®, others), valproic acid (Depakene®), divalproex sodium (Depakote®), lamotrigine (Lamictal®) and asenapine (Saphris®)

Lower risk (+/- risk of weight gain)


Antidepressants venlafaxine (Effexor®), bupropion (Wellbutrin®),

Selective serotonin reuptake inhibitors (SSRIs) other than paroxetine (Paxil)

fluoxetine (Prozac®), sertraline (Zoloft®), citalopram (Celexa®) and escitalopram (Lexapro®)

Antipsychotics * Higher risk when combined with a mood

stabilizer

ziprasidone (Geodon®), aripiprazole (Abilify®, Abilitat®)

Sources: 1. J Clin Psychiatry 2003. 64:598-604. 2. Mayo Clinic Drugs and Supplements (2011). http://www.mayoclinic.com/health-information/. 3. Wirshing DA. Schizophrenia and obesity: impact of antipsychotic medications. J Clin Psychiatry 2004. 65(S18):47-56. 4. Woo V, Harris SB and Houlden RL. Canadian Diabetes Association Position Paper: Antipsychotic Medications and Associated Risk of Weight Gain

and Diabetes. Can J Diabetes 2005; 29(2):111-112.

Notes: 1. The monitoring outlined in these guidelines does not supersede specific monitoring requirements for other psychotropic drugs (e.g., clozapine).

http://www.bcguidelines.ca/gpac/


AUTHORIZATION:


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Table 8 – Atypical antipsychotics and metabolic abnormalities

Drug (generic) Drug (trade name) Weight gain Risk of diabetes Worsening lipids

Aripriprazole 1 Abilify, Abilitat +/- +/- -

Clozapine Clorazil +++ + +

Olanzapine Zyprexa +++ + +

Quetiapine Seroquel +/++ D D

Risperidone Risperdal ++ D D

Ziprasidone 1 Geodon +/- +/- -

Legend : + = increased effect, - = no effect, D = discrepant

Notes :

1. Newer agents with limited long-term data.

Source: Woo V, Harris SB and Houlden RL. Canadian Diabetes Association Position Paper: Antipsychotic Medications and Associated Risk of Weight Gain and Diabetes. Can J Diabetes 2005; 29(2):111-112.

Table 9 – Signs and symptoms of diabetes and DKA checklist

Diabetic ketoacidosis (DKA) is an acute and severe complication of diabetes. It can be life threatening and requires emergency treatment. It is important to be able to recognize, and differentiate between, the signs and symptoms of both diabetes and diabetic ketoacidosis.

Diabetes Diabetic ketoacidosis (DKA)

Unusual thirst Frequent urination Weight change (gain or loss) Extreme fatigue or loss of energy Blurred vision Frequent or recurring infections Cuts and bruises that are slow to heal Tingling or numbness of the hands or feet Trouble getting or maintaining an erection

Fruity smell on breath Shortness of breath Confusion Nausea Vomiting Weight loss

Source: Canadian Diabetes Association (2011). www.diabetes.ca.

clinical practice guideline title: metabolic monitoring in ... monitoring in adult mental... ·...

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