June 1, 2023

One of the biggest challenges we face in the field of psychiatry is medication adherence. A large portion of the people fail to get better either because they do not start the medication, or do not take it as prescribed. One of the most common reason cited by patients for stopping medication is weight gain. In this article I will detail the approach I take to weight management for patients on psychiatric medications.

What’s up everybody dr ozzy shrinks at sneakers.com i’m going to tackle a topic that i think a lot of people have questions about and my patients certainly always have questions about and that is the topic of psychiatric medication-induced weight gain and what to do about it what is my approach to solving this problem or dealing with this issue when it comes up

Now we know that one of the biggest challenges in psychiatry is medication adherence one of the challenges is getting people to you know take medication on a regular basis it’s hard i mean even medicine doctors in internal medicine or whatever have trouble with this same issue so a large portion of people fail to get better because they either don’t start the

Medication right they get the prescription and they never start it or they don’t take the medication that’s prescribed they kind of take it when they feel like it or in the case that we’re talking about here they have a specific side effect that they don’t like and then they stop taking it but they don’t ever tell the doctor right they don’t ever come to me and

Say hey like i’ve been taking this medication i’m having this side effect i don’t like it what can we do about it so one of the most common reasons for stopping medication or that’s cited by many patients is weight gain so we’re going to talk about weight gain here and i’m going to detail kind of my approach it’s like a three-step approach to treating weight

Gain so for me weight management begins on the initial visit it’s something you want to talk about right away if you’re prescribing medication now i don’t always prescribe medication on my initial visit a lot of times i’ll tell people let’s do some labs let’s look at some other stuff and then let’s try maybe some cbt or something like that and then if you’re

Still having an issue you could come back to me and we could talk about medication but let’s say you’ve already decided you’re going to prescribe the medication to the patient and you want to work on preventing weight gain before it even happens so that’s the first point the me the discussion starts on the initial visit now we do obtain some objective measures so

We always do height weight and we calculate a bmi for every patient every time they come in so we can track the progress and to track the weight gain or weight loss depending on what the circumstances are additional tests we might order is a lipid profile if we have some concerns about lipid levels we might order an hba1c so that’s a hemoglobin a1c level to see

Whether or not a person would say diabetes has been well controlled or not well controlled so we can and a fasting glucose obviously those three things together might be some initial tests that we order to check to see how the patient is doing now for people with little diet or exercise experience i keep the information very basic and i think that’s important

Sometimes we put too much technical jargon in our discussions and people don’t understand it and they don’t know how to use it practically so i’ll keep it really really simple and i’ll say things like why don’t we just start with eliminating a couple easy things we can eliminate so if you’re drinking sugary beverages like soda or iced tea that’s got 30 grams of

Sugar in every one that you drink let’s just stop drinking those and let’s focus on drinking things like water and green tea right if we focus on those things that’s a really simple intervention that’s going to help somebody manage their weight much easier so we start there the next thing i’ll say is things like processed foods if you can eliminate processed

Foods things like microwavable dinners if you’re eating those kind of things things like you know chips and snacks that you find in your food store and let’s start supplementing those with different types of snacks why don’t we buy a bag of almonds why don’t we get some walnuts why don’t we go with a healthier trail mix that might still have things like dried

Fruit in it but aren’t going to have the calorie content that some of these processed foods are going to have if you’re eating things like white breads right you can switch to things like multigrain bread etc so we’ll keep it really simple eliminate processed foods calorie containing beverage beverages and simply increase your intake of fruits and vegetables

You know sometimes people get bogged down this idea that fruits have a lot of sugar in them and they can actually cause weight gain but i’ve never seen anyone get become overweight because they were simply eating too much fruit most of the time when people are gaining weight it’s because again they’re eating the processed foods the sugary beverages and they’re

Not really eating many fruits or vegetables so increase your intake of fruits and vegetables very simple you know and when you’re making choices at the at the food store you know keep those things in mind it’s a real simple basic way to kind of handle this i also have a couple of handouts that i use that sort of detail how you can go about your grocery shopping

Looking for foods that make the most sense so that’s the place i would start with these people and then i would also recommend they track their food intake and beverage intake right because what what ultimately happens is people think they’re doing a good job a lot of times with their diet and they’re not because they’re not tracking it they don’t actually know

What they’re taking in how much they’re taking in so i recommend you either keep a food diary written one in a book if you prefer that or if you’re into technology there’s a bunch of apps out there one’s called myfitnesspal that allows you to kind of track your food intake and put everything into it so if you prefer apps that would be a recommendation so then

What we do is we build on the diet interventions and we monitor progress from the food diary and we can make additional interventions and changes as needed depending on how the patient responds to the medication depending on whether or not there’s any weight gain starting i don’t recommend specific diets to my patients i want to keep it again as simple as

Possible and honestly dietary information first of all everything’s cyclical so what you’ll see is the fad diets that were popular you know 20 years ago come back around and again become popular again okay so the next step we talked about diet we talked about exercise now we gotta talk medication choice so what i will do with my patients is i’ll try to choose

Some medication that’s going to limit the potential for weight gain that’s what you want to do you want to make decisions like if weight gain is a real issue for this person that you’ve identified or if they’re already struggling with weight gain prior to starting a psychiatric medication then we want to make sure we’re not choosing medications that are going

To make that situation worse however most psychiatric medications cause weight gain so that’s something we’re already battling against this is an unavoidable fact in many cases but we can avoid certain medications that have the highest propensity for weight gain and those medications that come to mind when we’re thinking about this are things like clozapine or

Lanzapine or cyprexa and mirtazapine or remeron which is an antidepressant medication so two of those are dopamine blocking medications one is a serotonin-based drug that um that is is also an issue right so these are the ones that cause the most weight gain and it’s good planning on the physician’s part to kind of be mindful to avoid those medications at least

Initially unless the patient really needs them and in the case of clozapine and orlanzipine they tend to be more effective dopamine blocking medications and for more severe mental illness it’s important to note also that things like ariepipperzoll often get noted as being weight neutral meaning they don’t cause any propensity for weight gain however in clinical

Experience i’ve seen weight gain in things like aeropresle just like i’ve seen with other medications maybe not to the extent of things like orlanzapine or clozapine but still weight gain nonetheless so being mindful that they’re not they’re not necessarily even if they say they’re weight neutral in the literature it’s not a hundred percent a guarantee that there

Will be weight neutral and some of the other medications like lorazeidone that are weight neutral are hard to get prescribed because of prior authorization and the requirement to show they’ve that a patient has failed other medication trials so sometimes prescribing the medication you want to prescribe is not easy or possible so we finally come to the last part

Here and that is pharmacological intervention for weight gain so my last line of defense you know people again always accusing us of prescribing too many medications i would say that this is the last defense right this is the last thing you would do if a person is on one of these medications that causes weight gain and is having significant weight gain and you

Don’t and you don’t know what to do because their their diet and exercise isn’t working we need to do something to try to help this person so last line of defense we would use a medication specifically i like to use metformin extended release 500 milligrams daily after the largest meal so metformin is a diabetes drug usually used in type 2 diabetics and it does

Not cause hypoglycemia person’s not going to have a you know severe hypoglycemia as a result of taking this medication and there’s a lot of good evidence in the literature to support its use in antipsychotic or dopamine blocking medication induced weight gain so we have some literature to support our decision here and we know that we’re not really going to be at

Risk of serious adverse side effects here with this medication of course you want to be mindful of the you know patients other comorbidities and other medications they’re taking make sure you’re not you know again doing anything dangerous but if let’s just say the patient is fine to take this medication it’s a good place to start and the ultimate goal would be to

Start with the 500 milligrams of extended release with the largest meal with the goal of titrating to 2 000 milligrams a day in divided doses you want to check a b12 level vitamin b12 level you check it once per year as metformin has been known to reduce levels one simple way to deal with this is to just have the patient take some b12 it’s not going to hurt so

Over the counter b12 medication again there’s there’s a lot of evidence in the literature there’s even some meta-analyses so meta-analyses take all the randomized controlled trials and look at all the data and conclude whether or not it’s an effective drug so metformin is effective for preventing and reducing antipsychotic induced weight gain or dopamine blocking

Medication weight gain if that doesn’t work or for some reason the patient can’t take metformin there are other options another option that’s very common is topiramate so topiramate okay or topomax it’s also known as topomax it’s sometimes used in bipolar disorder although not very effective for mood stabilization there is evidence to support the use of topiramate

For antipsychotic induced weight gain again this comes from randomized controlled trials so there’s greater weight loss in the meta-analyses of to paramate over antipsychotic over placebo and the mean decrease is 2.8 kilograms so 2.8 kilograms not that much weight but you know it’s better than placebo and if someone’s really struggling you may need to go this

Route if you’re going to use teparamate the dose has to be 100 to 200 milligrams depending on the patient’s tolerance and when we talk about superimate it’s also called topomax it’s also called dopamax and the reason behind that is because some people experience some cognitive issues on to pyramid and they feel like they’re not thinking as clearly or as easily

And are having trouble in that regard so being mindful of watching to see if people are having that type of side effect and getting to an effective dose of teparamate can take some time now recently i just want to talk briefly the fda approved a medication called semiglutid semilutide and this is an injectable diabetes medication for chronic weight management

So this has been fda approved now for chronic weight management in adults with obesity and one related condition so that would be something like hypertension so they have to have obesity hypertension you can now you can now prescribe this medication and this medication acts like glucagon right it acts like glucagon so it’s called a glucagon-like peptide one

Agonist glp-1 agonist that’s the mechanism of action not that important as an injectable medication that you take 2.4 milligrams once weekly um there’s also another version of it called lyra glutid so there’s semiglutid and there’s lyric glue tied and i think each of those would be reasonable choices the limiting factor in this it is very exciting that it helped

People to lose weight whether you’re struggling with obesity and comorbid conditions but the issue is it’s very expensive and i’ve kind of wrote in some of my comments people have asked me about those those type of things in prescribing like should we prescribe generics versus brand names well a lot of times it’s going to come down to cost and a lot of patients

Don’t have the money to buy brand name drugs they have to use generic drugs because they’re they’re they they don’t have the money sit plain and simple i mean so being mindful of what the cost is for the potential benefit so that wraps the video that covers all my methods at least initially for preventing weight gain or treating weight gain from psychiatric medications

Transcribed from video
Help Doctor I’m Gaining Weight: Psychiatric Medication Induced Weight Gain By Shrinks In Sneakers