I too get very frustrated when my neurologist blows off some symptom as being unrelated to PD. But neurologists are not receiving the best training. Since drug companies offer "credit classes" for free for physicians to take to keep their continiuing credits education up to date, they may be missing out on courses which would be of more value when working with patients. I refer you to the following research study:

SAN FRANCISCO— Nearly 90% of psychiatrists recognize that atypical antipsychotic drugs differ significantly regarding their association with metabolic dysfunction. However, although a majority acknowledges that diabetes and weight gain may result from these drugs, many more are unaware of other serious metabolic disorders that can occur. These were among the key findings of a survey that evaluated physicians’ management of metabolic complications in patients taking atypical antipsychotics.

“[Psychiatrists] do recognize that select atypicals pose a greater risk for metabolic disorders, and that these are sometimes unrecognized because monitoring is not being done sufficiently,” said Henry Nasrallah, MD. “Atypical antipsychotics are not all the same. This is one of the key issues in psychiatric practice.” Dr. Nasrallah is a Professor of Psychiatry, Neurology, and Neuroscience and Associate Dean of the University of Cincinnati College of Medicine.

“I think the real issue for the field is that people are waiting for some kind of a consensus, evidence-based guideline that helps psychiatrists judge the different risks and benefits of the various drugs,” added P. Murali Doraiswamy, MD. Dr. Doraiswamy is Chief of the Division of Biological Psychiatry in the Department of Psychiatry at Duke University Medical Center in Durham, North Carolina. Both physicians made their presentations at the 156th Annual Meeting of the American Psychiatric Association.

ATYPICAL ANTIPSYCHOTIC AWARENESS

The survey included 300 randomly selected US physicians who treated at least eight patients with schizophrenia and related disorders per month. The goal was to assess the extent of physician awareness as to the adverse effects of antipsychotic drugs, the physician’s perception of metabolic disorders, and the extent to which their clinical practice was affected by these problems.

Dr. Doraiswamy addressed a number of questions from the survey, beginning with whether physicians found the body of evidence for a diabetes–atypical antipsychotics association to be compelling. “An overwhelming majority of psychiatrists (84%) either agreed or strongly agreed that this was the case,” he said. “There have been good data suggesting that schizophrenia itself may be associated with a number of risk factors for diabetes. Schizophrenics get poor medical care. Many of them don’t routinely get preventive health care, so they may have preexisting risk factors. What doctors are saying is that in addition to those risk factors, they believe there is also a link between some atypical antipsychotic agents and diabetes.”

Physicians were also asked if they viewed current reports of diabetes and other metabolic changes resulting from some atypical antipsychotics as not clinically significant. Dr. Doraiswamy said that about 76% of psychiatrists disagreed or strongly disagreed. “In other words, most doctors viewed these reports as clinically significant, because they are aware of the implications that diabetes and metabolic complications confer on the overall health risks for the patient.”

About 71% of psychiatrists either agreed or strongly agreed that the development of metabolic issues associated with some atypical antipsychotics makes it much more difficult to manage schizophrenia. “Patients with schizophrenia are already having a hard time dealing with their mental illness, and if you have a second metabolic complication on top of that, it makes it much more difficult,” Dr. Doraiswamy commented. Approximately 91% of psychiatrists believed that the development of metabolic issues had a negative impact on patient compliance. “If they have side effects with these medications, then patients may stop taking these medications without even informing their health care practitioner,” he said.

On another topic, 62% of practitioners either agreed or strongly agreed that metabolic issues would negatively affect the efficacy of antipsychotic therapy. “When we think about efficacy, we are really looking at short-term clinical trials, and in short-term clinical trials there is really no difference as far as the efficacy of most antipsychotic drugs,” said Dr. Doraiswamy. “Clearly, we need long-term studies to tease out this particular issue.”

Asked if they believed that atypical antipsychotic agents differed significantly in their likeliness to cause metabolic dysfunction, 87% of psychiatrists either agreed or strongly agreed. “Even though they may still think that all these drugs can sometimes cause some of these effects, they believe there is a difference in risk,” said Dr. Doraiswamy. “They believe that not all atypical drugs are the same as far as their ability to cause metabolic illness. And this also, I think, tells us that they believe that all these effects are not entirely due to the disease itself.”

RISK PREVENTION

Dr. Nasrallah also addressed the issue of risk prevention and antipsychotic medication. “In medicine, one of the key principles or guidelines for physicians is ‘Above all, do no harm.’ We recognize that all medications have side effects, but one can adopt a policy in managing patients in which you get the maximum possible efficacy with the least amount of harm.” He noted that approximately 72% of psychiatrists agreed or strongly agreed that first-line agents associated with significant weight gain or other metabolic risks should not be considered for initial therapy.

The survey also found that the majority of physicians believe that patients with schizophrenia generally already have a higher risk for metabolic complications than does the general population. “Patients with psychosis—schizophrenia, especially—tend to be overweight, have a very poor lifestyle and poor nutritional habits, and they rarely exercise,” noted Dr. Nasrallah. “They have multiple risk factors, and on top of that they also have diabetes.” Furthermore, a “vast majority” of psychiatrists believe that weight gain contributes to the development of metabolic issues or disorders in patients with schizophrenia. “It is a no-brainer that weight gain is one of the most important initial foundations of metabolic disorders,” he said.

As to what metabolic adverse effects, if any, were associated with some atypical antipsychotic drugs, two thirds of psychiatrists were concerned about diabetes and the majority were concerned about weight gain in their patients. However, metabolic complications such as change in lipids, hyperglycemia, obesity, and increased glucose were noted far less frequently. For most patients, weight gain is an acceptable risk in return for other benefits of antipsychotics, Dr. Nasrallah said. “About 43% [of psychiatrists] agree that diabetes is an acceptable risk factor in return for the other benefits of atypical antipsychotics. When you compare that with 67% who acknowledge that diabetes is a serious side effect, what this tells you is that some psychiatrists are so eager to get rid of the hallucinations of the patients that they would allow the patient to have diabetes in return for that. I personally don’t believe that is a good risk to take.”

STRIVING FOR BETTER CARE

Dr. Nasrallah pointed out that 35% to 40% of patients are switched within a year from one antipsychotic drug to another, because either the drug is not working or the drug is causing a lot of adverse effects. “You cannot tell if your patient is developing a serious medical problem unless you look,” said Dr. Nasrallah. “There has been no consistent national guideline for monitoring these serious metabolic side effects, despite the fact that they are the hottest topic in the country. [Rates of] diabetes are increasing, weight gain is increasing, high lipids and cholesterol are increasing. Are you looking for it? Are you measuring them at baseline and following up the patient?” When asked if first-line agents associated with significant weight gain or other metabolic risks should not be considered for initial therapy, however, only 28% of psychiatrists surveyed agreed or strongly agreed. “Certain atypicals are guaranteed to give you more than 20 pounds of weight gain within a year; others, zero weight gain in a year.”

Physicians were asked how many patients with schizophrenia and related disorders were routinely monitored for various health concerns. One third said that they monitored all their patients for blood pressure. “That’s such an important public health screening for hypertension, which again is one of the metabolic disorders,” said Dr. Nasrallah. About 63% measured or were cognizant of the weight of their patients; 29% measured lipid levels; and 43% screened for blood glucose. “Despite the fact that they’re aware of the seriousness of the problems, there’s still not sufficient monitoring going on,” said Dr. Nasrallah.

Dr. Nasrallah emphasized that psychiatrists who prescribe antipsychotics need to consider all metabolic consequences before selecting the first-line drug. Furthermore, he said, “Ongoing education is important to minimize risk. I’m a strong believer in patient education, parent education, and, of course, physician education.”

—Colby Stong

From current issue of "Neurology Today."

Although the article refers to schizophrenia, it applys to PD patients. PD is the counterpart illness to schizophrenia; I.E., schizophrenia is too much dopamine; PD is not enough.

Vicky