Glucose Monitoring and Antipsychotic Medication An Audit by Dr Emma Kelson

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Glucose Monitoring and Antipsychotic Medication
An Audit by Dr Emma Kelson

• Presented by Dr Yas Daudjee

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Background

• Research suggests antipsychotics increase blood
  glucose
• Possibly more so by the atypicals
• Elevated blood glucose may be a marker for future
  impaired glucose tolerance, insulin resistance,
  Type 2 diabetes and the metabolic syndrome

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Aims

• Do we meet AWP standards for blood glucose
  monitoring in patients on antipsychotics?
• AWP standard baseline blood glucose check prior
  to prescribing any antipsychotic, and subsequent
  annual check

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Method

• Bristol Central CLDT database used to identify
  all patients on antipsychotics and their
  diagnosis. This information was confirmed by case
  note review
• Records reviewed by hand was blood glucose
  requested in the last year, and was the result
  documented?
• If not, GP surgeries were phoned up to see if the
  blood test had been done

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Results

• 62 patients identified
• 42 on atypicals
• Risperidone 18 oral, 1 IM
• Olanzapine 11
• Amisulpiride 4
• Quetiapine 3
• Aripiprazole - 3
• Clozapine 2
• 20 on typicals
• Zuclopenthixol 6 oral, 3 IM
• Sulpiride 4
• Benperidol 3
• Chlorpromazine - 2
• Trifluperazine 1
• Haloperidol 1

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Results continued

• 30 patients had blood tests in last year
• 22 patients had random blood glucose checked in
  last year (73 of those who had blood tests,
  35 of all patients on antipsychotics) all
  normal
• 15 out of the 42 on atypicals (68 of those who
  had blood glucose checked, 36 of all patients
  on atypical antipsychotics)
• 6 out of the 20 on typicals (30 of all patients
  on typicals)
• 15 requested by psychiatry (68), 6 requested by
  GP, 1 unknown (probably GP)
• 4 patients had blood glucose requested, but not
  done
• Unable to determine if baseline checked (most on
  antipsychotics gt 7 years)
• 3 of the 22 were inpatients, with blood glucose
  checked as an inpatient
• Only 7 documented in the medical notes prior to
  audit (32)

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FLOWCHART OF RESULTS
15
22
6
30
62
8
32
HAD BLOODS
TOTAL
HAD GLUCOSE
ATYPICAL/TYPICAL
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Discussion

• Good practice
• Inpatient bloods checked during admission
• 2/3 of atypicals are being checked
• Discussion points
• Just over a third of patients had blood glucose
  checked in last year
• Whose responsibility is it to request bloods,
  make sure patients have the tests and chase
  results us, GP or carers/patients? Would we get
  better results if we filled out blood forms
  ourselves (with copies of tests to GPs) rather
  than asking for tests in our clinic letters
  (sometimes repeatedly)? What does the legal
  responsibility lie does the doctor who asks for
  the blood test have a duty to follow it up and
  act on the result?
• No gold standard for monitoring, but AWP have
  guidance as do Maudsley. There are significant
  difference between them though. Does BANES have a
  policy which we should be following currently?
• Different GP surgeries have different systems of
  monitoring. Are there shared care protocols
  operating?
• Is the one page AWP summary of required tests
  disseminated to GPs?
• What is the role of pharmacists?

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Comparison to National Audit

• The Prescribing Observatory for Mental Health
  (POMH) is a national quality improvement
  programme open to all specialist mental health
  services, based at the RCPsychs Centre for
  Quality Improvement. Their aim is to help mental
  health services monitor and maintain or improve
  the quality of their mental health prescribing
  practice.
• What does POMH do? - Identifies Topics within
  mental health prescribing that warrant attention,
  and develops for each a programme of clinical
  audit and quality improvement to help services
  improve in that area
• Current Topics
• Rx of high-dose and combination antipsychotics on
  adult acute PICU wards
• Screening for metabolic side effects of
  antipsychotics among assertive outreach team
  patients
• Rx of high-dose and combination antipsychotics on
  forensic wards
• Benchmarking the Rx of anti-dementia drugs (from
  June 2007)
• Benchmarking the Rx high-dose and combination
  antipsychotics on adult acute PICU wards
  (extension of Topic 1)
• Assessment and monitoring of side effects of
  psychotropic medication (in development)

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UK Audit

• Minimum audit standard all patients should have
  BP, BMI (or other measurement of obesity such as
  waist circumference), blood glucose (or HbA1c)
  and plasma lipids yearly
• Audit of 1966 patients of 48 AO teams (21 mental
  health trusts)
• BP 26, obesity 17, blood glucose (or HbA1c)
  28, plasma lipids 22
• All 4 measurements documented in 11
• Range of morbidity 6 diabetes (50 of
  expected), 6 hypertension (20 of expected), 6
  dyslipidaemia (13 expected)
• Questionnaire of obstacles uncertainty about
  responsibility, lack of confidence about
  interpretation of abnormal results, limited
  access to basic equipment

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Re-Audit Comparison (2004 and 2007)

• Number of patients on antipsychotics 82 (in
  2004), 62 (in 2007)
• of patient population on antipsychotic drugs
  49 in 2004, 45 in 2007
• Number of patients prescribed drugs within BNF
  dosage 100 in both audits (Compared with POMH
  data only 36 with BNF dosage)
• Number of patients prescribed within licenceoff
  licence
• 2004 5530
• 2007 4852
• Off licence number of prescriptions increased
  slightly (26 up to 35), but very different
  indications between the two audits, for example
  2004 indication of autism changed in 2007 to
  Generalised Anxiety Disorder
• Depot 9 (in 2004), 5 (in 2007)
• Patients without psychiatric diagnosis, but with
  challenging behaviour 10 in 2004 (12), 9 in
  2007 (15)
• Patients without any diagnosis 8 in 2004
  (10), 5 in 2007 (8)
• Number of patients on atypicalstypicals
• 2004 6337
• 2007 6832
• Risperidone - 63 in 2004, 45 in 2007

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Suggested Recommendations

• Psychiatrists to routinely ask for blood glucose
  on initiation of antipsychotics, and annually
  thereafter
• Psychiatrists to remember to ask for blood
  glucose in letters when requesting blood tests
  from GPs
• Psychiatrists to chase up blood tests when
  results are not forwarded on to us
• Clinical Governance Lead to consider the issue of
  shared care protocols for physical healthcare
  monitoring for patients on antipsychotic
  medication

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Agreed Recommendations

• Psychiatrists to routinely ask for blood glucose
  test on initiation of antipsychotics, and
  annually thereafter
• Agreed at academic meeting by medical staff on
  14/11/07