Skip to content
My WebMD Sign In, Sign Up

Announcements

Visit our Crisis Assistance Link for resources. For immediate help, get to the ER.

*No Dr Outside Contact Please*
Includes Expert Content
Type II diabetes and atypical antipsychotics (Dr. G question)
avatar
reneegigliotti posted:
This is what I know thus far: atypical antipsychotics have been "black boxed" for type II diabetes on the package insert for a number of years. I take 600 mg of seroquel PM and 200 mg in the AM (gastric bipass surgery makes my dosing a bit higher than most people). I had been having episodes of hypoglycemia (numbers dipping down into the mid 30s randomly) for about a year. My PCP did a routine HbA1C blood draw and it was 10.8. My non-fasting serum glucose was 479. My PCP sent me to an endocrinologist and she believes that it may be a combination of my history with gestational diabetes, the GBS, and an influence of the seroquel. However, since I have a long history of difficult to treat mania with psychosis, neither my endocrinologist nor my psychiatrist want to touch the seroquel or it's dosing because it is working for me. They both agree treating the diabetes is an easier task when I'm not psychotic. My question, just out of curiosity, what other antipsychotics might be effective at dealing with psychosis with mania that do not have the adverse event of type II diabetes. I realize I'm never going to win a med change debate with my psychiatrist, he's worked pretty hard try to find a drug or combination of drugs that keep me stable but not overly medicated. However, I'm really curious if anything is else is available. I hate having to inject insulin.
Reply
 
avatar
Joseph F Goldberg, MD responded:
Dear reneegigliotti,
Many atypical antipsychotics can oppose the action of insulin (which is responsible for transporting sugar from the bloodstream into organs) which over time can result in both weight gain and high blood sugars with insulin resistance, posing a risk for diabetes. In someone who already has diabetes (as your numbers reflect), there is a risk-benefit issue regarding which atypical antipsychotic may be safest as well as most effective without further aggravating insulin resistance. An argument can be made for continuing the Seroquel is it is indeed helping and other agents that carry a lesser risk for diabetes have proven unhelpful. Two questions come to mind though: first, antipsychotics such as Seroquel are often used short-term when someone is in a manic episode but not necessarily kept long-term, for which mood stabilizers such as Depakote, Tegretol or lithium are more customary. If your doctors believe that psychosis occurs for you only when manic, then one or more mood stabilizers such as these may help prevent psychotic mood episodes without the need for any antipsychotic as a long-term preventative agent. A second question is whether you and your doctor have discussed (or tried) any of the atypical antipsychotics which appear to carry a lesser risk for metabolic side effects, such as Latuda or Saphris. Saphris may be especially worth considering since it is absorbed under the tongue through the musoca in your mouth, rather than through the gastrointestinal tract, meaning that it poses no issues for absorption after gastric bypass. Lastly, in the setting of diabetes, some authorities would recommend an older typical rather than atypical antipsychotic (eg, Haldol, Trilafon, Prolixin, Navane), agents which treat psychosis entirely as effectively as atypical antipsychotics do but without the metabolic risk.

Things to consider and discuss with your doctors.

Dr. G.
 
avatar
reneegigliotti replied to Joseph F Goldberg, MD's response:
Very interesting. I am on both lithium and Depakote as mood stabilizers. It wasn't until the addition of Seroquel was there a marked improvement in both the number and duration of the psychotic episodes associated with mania. He tried weaning me several times from the Seroquel upon resolution of mania and psychosis only to have me relapse in a short time frame. He has also tried Xyprexa and Risperdal as well. At one point, in-patient, we tried trilafon. Seroquel had the most sustained positive impact in terms of staving off psychosis in conjunction with mania for me. He has never tried Latuda or Saphris. I like the idea of sublingual administration. It has been a challenge to maintain target blood levels, especially with the Depakote. Since it's a larger molecule than Li it would make sense that absorption would be more impaired. You are correct, it is a risk benefit calculation. He may not have thought of the two drugs you mentioned, however. I'll bring them up to him when I see him after his vacation. I have an additional question. Is the onset of type ii diabetes a dose/response type of adverse event or is it more of a cumulative exposure to the drug where actual dosing isn't really relevant. Also, can blood sugars normalize upon succession of administration or is the AE a permanent consequence?
 
avatar
Joseph F Goldberg, MD replied to reneegigliotti's response:
Dear Renee,
Excellent questions. Drug dose has not been identified as a risk factor or contributor either to short-term changes in blood sugar or eventual diabetes. Atypical antipsychotics can oppose the action of insulin, whose job is to chaperone glucose from the bloodstream into body organs; over time, prolonged insulin resistance can lead to weight gain and other metabolic changes including diabetes. Diabetes in the progressive end result over time of the body's inability to manage blood sugar. The process, if it occurs, usually takes many years.
Blood sugars can normalize if an offending agent is stopped, provided that a progressive chain of diabetes risk-factor events has not occurred (eg, weight gain, family history, prolonged hyperglycemia and insulin resistance). (If of interest, my book on managing psychotropic drug side effects covers these issues in more detail -- can probably find a used copy on Amazon for not too much.)
Also after gastric bypass be sure you are only taking immediate release -- not extended release -- formulations of all medicines, since XR drug forms of drugs are more poorly absorbed after bypass.
Dr G
 
avatar
reneegigliotti replied to Joseph F Goldberg, MD's response:
Excellent response. Thank you. It definitely helped. I know my Dr. G is one of the most caring and conscientious psychiatrists I've ever had to deal with. He's been my MD now for 18 years and he has seen me through some pretty harrowing psychotic/manic episodes and managed to keep me employed at a high level. As he once said to me " you have definitely presented me with some serious moments of concern over the decades, but we've done good work together". I like and respect him immensely. I do my part by being compliant and by presenting him with new ideas. No one can know everything. I like that he trusts me (except when I'm manic of course, lol). I will get your book and pull excerpts out for him. I bring him relevant journal article abstracts all the time. I'm also interested in trying to find a clinical trial that specifically deals with difficult to treat mania with psychosis. CT.gov doesn't have one listed right now that is open to accrual. I'm hoping the NIMH has funded one under development. I appreciate your time. Hopefully my questions help someone else as well.


Featuring Experts

Joseph F. Goldberg, MD, is a Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. He also maintains a private prac...More

Helpful Tips

TO DROP MY WEIGHT, I DROPPED THE DIET SOFT DRINKS.
Been on Zonegran for about five years and a type II diabetic for 35 years using metaformin and insulin. It appears the jury is in for me on ... More
Was this Helpful?
6 of 10 found this helpful

Related News

There was an error with this newsfeed

Related Drug Reviews

  • Drug Name User Reviews

Report Problems With Your Medications to the FDA

FDAYou are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.