Evaluating Cardiometabolic risk screening and monitoring among Patients prescribed antipsychotic drugs (ECRSMA study)

Azfr Ali, Ruba Saleh ORCID: 0000-0003-0473-0337 (2023). Evaluating Cardiometabolic risk screening and monitoring among Patients prescribed antipsychotic drugs (ECRSMA study). University of Birmingham. Ph.D.

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Abstract

Background: Antipsychotics have been associated with cardiometabolic side effects despite their wide use and effectiveness. Routine cardiometabolic monitoring of patients prescribed antipsychotics is recommended by clinical guidelines, including the National Institute for Health and Care Excellence (NICE). However, the evidence indicated suboptimal monitoring practices. This PhD work aims to evaluate the level of cardiometabolic monitoring in patients prescribed antipsychotics in primary care according to the guidelines and factors associated with adherence to monitoring guidelines.
Methods: The programme of work presented in the thesis was conducted in two stages. A systematic literature review was conducted to i) understand the epidemiology of the cardiometabolic side effects of antipsychotics; the available interventions to mitigate these side effects, and ii) identify the barriers to effective monitoring of these side effects. A population-based, retrospective, observational and open-cohort study was then conducted to evaluate the extent of cardiometabolic monitoring in patients prescribed antipsychotics. The Health Improvement Network (THIN) database incorporating electronic medical records from general practices throughout the UK, representing ≈ 6% of UK general practice registrants, was used to identify a cohort of patients on chronic antipsychotic therapy for mental illnesses. The NICE guideline for Psychosis and Schizophrenia in adults [CG178] was used as the reference standard to assess monitoring practices. Also, the association between antipsychotic drugs prescribed at the study index and monitoring practices was investigated through regression modelling by measuring the odds of monitoring events at different time points.
Results: The review showed various but high prevalence of cardiometabolic side effects among antipsychotic users. Information on the cardiometabolic profile for individual antipsychotics was scarce. Several interventions are available to counter these side effects. Some pharmacological and non-pharmacological interventions demonstrated promising effects to counteract some cardiometabolic side effects of antipsychotics mainly weight gain. The qualitative component of the review identified several intrinsic (e.g., mental health stigma) and extrinsic factors (e.g., fragmented healthcare) that can hinder the management and monitoring of cardiometabolic side effects of antipsychotics. The THIN study showed suboptimal cardiometabolic monitoring levels in primary care. A total of 11,435 records for adult patients with mental illness and prescribed antipsychotics were included. Of these patients, 9707 (85%) were prescribed second-generation antipsychotics. The majority (n=11,145, 97%) failed to receive complete monitoring for any of the study outcomes. 52% of the patients (n= 6,599) had evidence of any cardiometabolic monitoring for any of the study outcomes (e.g., BMI records) and the majority had at least one abnormal lab value at baseline (n=4,627, 97%). Additionally, waist circumference and blood glucose levels were the least recorded in the screened records (≈5% and <30%). Among different antipsychotics, the recorded monitoring frequency did not surpass 52% for any outcomes at any time point. The regression analysis showed that prescribing antipsychotics with high cardiometabolic risks (e.g., olanzapine) did not promote cardiometabolic monitoring (OR: 04-1.2, P>0.05).
Conclusions: In UK primary care, cardiometabolic monitoring practices in antipsychotic users remains suboptimal. Baseline and follow-up cardiometabolic monitoring was infrequent, irregular, and did not change in response to the use of high cardiometabolic risks antipsychotics. The barriers to optimum monitoring could be multifactorial. Pharmacists' participation in the monitoring process is essential to enforcing cardiometabolic monitoring guidelines for antipsychotic drugs.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):