R4R Physical Health in Mental Health · Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley...

This programme has been organised and

funded by Janssen.

R4R: Physical Health in Mental Health

Adverse events should be reported. Reporting forms and information can be found

at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google

Play or Apple App Store. Adverse events should also be reported to Janssen-Cilag

Limited on 01494 567447 or at [email protected].

Item code: PHGB/MEDed/0418/0014

Date of preparation: June 2018

http://www.mhra.gov.uk/yellowcard

mailto:[email protected]

Welcome to the R4R: Physical Health in Mental Health

Online Training ModuleThis module has been created for mental health professionals to enhance their

understanding of ways to improve the physical health and wellbeing of people living with

mental health issues. This module provides information on how to identify, manage and

monitor a number of physical health problems through addressing key risk factors and

examining patient case studies.

This module has been sponsored and developed by Janssen-Cilag Limited, and has been

designed to benefit you, your team and your patients. The content has been written by Louise

Saxton RMN, Mental Health Clinical Nurse Specialist and Mednet Ltd.

By the end of this module, you will:

• Identify and discuss ways to improve the physical health and wellbeing of people living with mental

health problems, particularly schizophrenia.

• Gain understanding and knowledge of why improving physical health in mental health is important.

• Identify a number of the key risk factors for physical health problems, including common risks of

antipsychotic medication.

• Confidently and knowledgeably recognise, manage and monitor the following physical health

conditions:

• Neuroleptic Malignant Syndrome

• Diabetes

• Metabolic Syndrome

• Dehydration

Module aims

What does this percentage represent?

40%

What does this percentage represent?

Approximately 40% of

patients with

schizophrenia are obese.1

1. British Medical Association (2012) Quality and Outcomes Framework for 2012/13 Guidance for PCO and Practices. Available from:

https://www.myhealth.london.nhs.uk/sites/default/files/u1217/gpqofguidance20122013.pdf [Accessed June 2018].

https://www.myhealth.london.nhs.uk/sites/default/files/u1217/gpqofguidance20122013.pdf

What do these percentages represent?

85% 23%

What do these percentages represent?

85%23% general

population

1. Goff DC et al. (2005) Medical morbidity and mortality in schizophrenia: guidelines for psychiatrists. Journal of Clinical Psychiatry 66:183-194

Approximate

number of people

with schizophrenia

who smoke,

compared with…1

Be Aware Implications of Special Dietary Requirements

e.g. Low Vitamin D Diet

Implications of Special Dietary Requirements

• Shunning the sun, suffering from milk allergies, or adhering to a strict vegan diet means you may be at risk of vitamin D deficiency.1

• Known as ‘The Sunshine Vitamin’, vitamin D also occurs naturally in a few foods such as fish, fish liver oils, egg yolks and in fortified dairy and grain products.1

• Vitamin D is essential for strong bones, because it helps the body use calcium from the diet.1

• Traditionally, vitamin D deficiency has been associated with rickets, a disease in which the bone tissue doesn't properly mineralize, leading to soft bones and skeletal deformities.1

Vitamin D

1. WebMD (2017) Vitamin D Deficiency Available from: http://www.webmd.com/diet/guide/vitamin-d-deficiency [Accessed June 2018].

http://www.webmd.com/diet/guide/vitamin-d-deficiency

• The symptoms are subtle and include bone pain and muscle weakness.1

• Low blood levels of the vitamin have been associated with the following:1

• Increased risk of death from cardiovascular disease

• Cognitive impairment in older adults

• Severe asthma in children

• Cancer

• Research suggests that vitamin D could play a role in the prevention and treatment of a number of different conditions, including Type 1 & Type 2 diabetes, hypertension, glucose intolerance, and multiple sclerosis.1

Symptoms and Health Risks of Vitamin D Deficiency

1. WebMD (2017) Vitamin D Deficiency Available from: http://www.webmd.com/diet/guide/vitamin-d-deficiency [Accessed June 2018].

http://www.webmd.com/diet/guide/vitamin-d-deficiency

What is a Venous Thromboembolism (VTE)?

• VTE is a condition in which a blood clot (thrombus) forms in a vein.1

• It most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis.1

• The thrombus may dislodge from its site of origin to travel in the blood – a phenomenon called embolism.1

• VTE encompasses a range of clinical presentations: it is often asymptomatic; less frequently it causes pain and swelling in the leg.1

• Part or all of the thrombus can come free and travel to the lung as a potentially fatal pulmonary embolism.1

• Symptomatic venous thrombosis carries a considerable burden of morbidity, including long-term morbidity because of chronic venous insufficiency.1

Venous Thromboembolism (VTE)

1. National Institute for Health and Care Excellence (2015) Venous thromboembolism in adults admitted to hospital: reducing the risk. NICE clinical guideline [CG92] [Internet]

Available from: https://www.nice.org.uk/guidance/cg92 [Accessed June 2018].

https://www.nice.org.uk/guidance/cg92

Physical health in service users with serious mental illness; Why now?

• “We want people with mental health problems to live as long, and full a life as the rest of the population” (Department of Health, 2014)1

• Having a mental health problem increases the risk of physical ill health.1

• Currently, men with a severe mental illness die on average 20 years earlier than other people; women 15 years earlier.1

• People with severe mental illness have higher rates of cancer, heart disease, respiratory disease and diabetes.1

Integrating Physical and Mental Health

1. Department of Health (2014) Closing the Gap: Priorities for essential change in mental health. Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf [Accessed June 2018].

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf

• GPs and other primary healthcare professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually.1

• The health check should be comprehensive, focusing on health problems common in people with schizophrenia. Refer to relevant NICE guidance on monitoring for cardiovascular disease, diabetes, obesity and respiratory disease.1

• Identify people with psychosis or schizophrenia who have:

• high blood pressure

• abnormal lipid levels

• risk of obesity or are obese

• diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels)

• low levels of physical activity

at the earliest opportunity following relevant NICE guidance.1

NICE Clinical Guidance on Psychosis and Schizophrenia

1. National Institute for Health and Care Excellence (2014) Psychosis and schizophrenia in adults: prevention and management. NICE clinical guideline [CG178] [Internet]

Available from: https://www.nice.org.uk/guidance/cg178 [Accessed June 2018].


• The CQUIN payments framework was set up in 2009/2010 to encourage service providers to continually improve the quality of care provided to patients and to achieve transparency.1 CQUINs enable commissioners to reward excellence, by linking a proportion of service providers' income to the achievement of national and local quality improvement goals.1

CQUIN: Commissioning for Quality and Innovation

1. Royal College of Psychiatrists (2015) CQUIN Mental Health, 2014/2015, Available from: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/cquin.aspx [Accessed

June 2018].

2. NHS England. (2017) CQUIN Indicator Specification Information on CQUIN 2017/18 - 2018/19, Annex A Available from: https://www.england.nhs.uk/nhs-standard-

contract/cquin/cquin-17-19/ [Accessed February 2017].

2017/19 National CQUIN Goal2 Indicator2 Description and Weighting2

Improving physical healthcare to

reduce premature mortality in people

with serious mental illness.

Assessment and early

interventions offered on

lifestyle factors for

people admitted with serious

mental illness.

• Cardio metabolic assessment and treatment for patients

with psychoses (80%). Document in the patient’s

electronic care record: assessment results and

interventions offered (for patients who are identified as at

risk as per the red zone of the Lester Tool)

• Collaborating with primary care clinicians (20%).

• And in addition, for 2018/19: Demonstrate positive outcomes in relation to BMI and smoking cessation for patients in early intervention in psychosis (EIP) services.

http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/cquin.aspx

https://www.england.nhs.uk/nhs-standard-contract/cquin/cquin-17-19/

Lester UK: Positive Cardiometabolic Health Resource1

An intervention framework for people experiencing psychosis and schizophrenia

1. Image adapted from: Shiers DE, Rafi I, Cooper SJ, Holt RIG. (2014) 2014 update (with acknowledgement to the late Helen Lester for her contribution to the original 2012

version) Positive Cardiometabolic Health Resource: an intervention framework for patients with psychosis and schizophrenia. Royal College of Psychiatrists, London.

Improving lives of our service users and our practice

• Case Study 1: Kemi

• Case Study 2: Jerry

• Case Study 3: Jahan

• Case Study 4: Suzie

Physical Health Case Studies

Case Study 1

Kemi, age 25

Kemi has received an oil based First Generation Antipsychotic injection, as an initial

treatment.

She has become agitated, confused, complaining of pain, clear signs of muscle rigidity.

You record the following:

She has flushing to her face, appears hot, has a tremor and is anxious.

Case Study 1

• Kemi has received an oil based First Generation Antipsychotic injection, as an

initial dose. She has become agitated, confused, complaining of pain, clear

signs of muscle rigidity.

• Flushing to face, appears hot, tremor, anxious

Treatment history and Presentation

What actions should you take long-term?

What might be happening to her?

What are your actions likely to be?

Observations

Age 25

Temp 39°C

BP systolic 79mmHg

BP diastolic 50mmHg

Pulse 119

Respirations 24

BMI 24

O2 Sats 100%

AVPU Reacts to

Pain

Blood Sugar 4

Case Study 1 - Answers

Kemi has received an oil based First Generation Antipsychotic injection, as an initial

dose. She has become agitated, confused, complaining of pain, clear signs of muscle

rigidity. Flushing to face, appears hot, tremor, anxious


What actions should you take long-term?



Neuroleptic Malignant Syndrome

Withdraw antipsychotic medication.1

Monitor temperature, pulse and BP; IM benzodiazepines; referral to A&E/ medical

unit for: rehydration, bromocriptine + dantrolene, sedation with benzodiazepines and

artificial ventilation if required.1

Stop antipsychotics for at least 5 days, preferably longer. Allow time for symptoms

to resolve completely and then begin with a very small dose of antipsychotic and

monitor temperature, pulse and BP.1

Observations

Age 25

Temp 39°C

BP systolic 79mmHg

BP diastolic 50mmHg

Pulse 119

Respirations 24

BMI 24

O2 Sats 100%

AVPU Reacts to

Pain

Blood Sugar 4

1. Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell. pg.104

Neuroleptic Malignant Syndrome: signs, symptoms and risk factors


Signs and Symptoms1 Risk Factors1

• Fever, diaphoresis, rigidity, confusion,

fluctuating level of consciousness

• Fluctuating blood pressure, tachycardia

• Elevated creatine kinase, leukocytosis,

altered liver function tests

(presentation varies considerably)

• High potency first generation antipsychotics,

recent or rapid dose increase, rapid dose

reduction, abrupt withdrawal of

anticholinergics, antipsychotic polypharmacy

• Psychosis, organic brain disease, alcoholism,

Parkinson’s disease, hyperthyroidism,

psychomotor agitation, mental retardation

• Male gender, younger age

• Agitation, dehydration

• In the psychiatric unit:1

Withdraw antipsychotic; monitor temperature, pulse, blood pressure. Consider benzodiazepines if not already prescribed – IM lorazepam has been used.

• In the medical/ A&E unit:1

Rehydration, bromocriptine + dantrolene, sedation with benzodiazepines, artificial ventilation if required.

L-dopa, apomorphine and carbamezapine have also been used, among many other drugs. Consider ECT for treatment of psychosis.

NMS: treatment


What is Neuroleptic Malignant Syndrome?

• Neuroleptic Malignant Syndrome (NMS) is a rare but potentially serious or even fatal adverse effect of antipsychotics and medications with dopamine receptor-antagonist properties.1

• Although widely seen as an acute, severe syndrome, NMS may, in many cases, have few signs and symptoms and ‘full-blown’ NMS may thus represent the extreme of a range of non-malignant-related symptoms.1

Neuroleptic Malignant Syndrome


Case Study 2

Jerry, age 36

Jerry has received his oral second generation antipsychotic and oral treatment for

diabetes during the medicine round and you notice he appears slightly disorientated

and slightly drowsy.

You record the following:

Tremor and agitation, change in pallor observed.

Case Study 2

• Oral second generation antipsychotic and oral treatment for diabetes.

• Appears slightly disorientated and slightly drowsy.

• Tremor and agitation, change in pallor observed.


How often would you take Jerry’s vital signs?

What might be happening to him?


Observations

Age 36

Temp 36.5°C

BP systolic 115mmHg

BP diastolic 85mmHg

Pulse 108

Respirations 18

BMI 29

O2 Sats 98%

AVPU V

Blood Sugar 2


1. National Institute for Health and Care Excellence (2016) Type 1 diabetes in adults: diagnosis and management. NICE guideline [NG17] [Internet] Available from:

https://www.nice.org.uk/guidance/ng17 [Accessed June 2018].

Hypoglycemia


What are your actions likely to be?1

• Immediate treatment is to have a fast-acting form of glucose, if they are able to swallow.

• If they have decreased level of consciousness and unable to take oral treatment safely

you should: give intramuscular glucagon or intravenous glucose if skilled at obtaining

intravenous access.

• Then give an oral carbohydrate after 10 minutes, when safe to administer.

How often would you take Jerry’s vital signs?1

Monitor response at 10 minutes and if not improved significantly, administer glucose.

Continued observation by a 3rd party, who has been warned of the risk of relapse.

Observations

Age 36

Temp 36.5°C

BP

systolic

115m

mHg

BP

diastolic

85mm

Hg

Pulse 108

Respiratio

ns

18

BMI 29

O2 Sats 98%

AVPU V

Blood

Sugar

2

• Oral second generation antipsychotic and oral treatment for diabetes.

• Appears slightly disorientated and slightly drowsy.

• Tremor and agitation, change in pallor observed.


https://www.nice.org.uk/guidance/ng17

It is estimated for all adults and children:

• 10% of people with diabetes have Type 1 diabetes.1

• 90% of people with diabetes have Type 2 diabetes.1

Diabetes

1. Diabetes UK (2016) Diabetes: Facts and Stats Available from: https://www.diabetes.org.uk/Documents/Position%20statements/DiabetesUK_Facts_Stats_Oct16.pdf

[Accessed June 2018].

https://www.diabetes.org.uk/Documents/Position statements/DiabetesUK_Facts_Stats_Oct16.pdf

Type 1 Diabetes

• Although more than 85% of Type 1 diabetes occurs in individuals with no previous first degree family history, the risk among first degree relatives is about 15 times higher than in the general population.1

Type 2 Diabetes

• There is a complex interplay of genetic and environmental factors in Type 2 diabetes. It tends to cluster in families.1

• People with diabetes in the family are two to six times more likely to have diabetes than people without diabetes in the family.1

• Obesity is the most potent risk factor for Type 2 diabetes. It accounts for 80– 85% of the overall risk of developing Type 2 diabetes.1

Diabetes and Genes




• People from South Asian and Black communities are two to four times more likely to develop Type 2 diabetes than those from Caucasian backgrounds.1

• Age and sex standardised prevalence rates (per 100) of Type 2 diabetes according to ethnic group in the UK:2

• White 1.7%

• Chinese 3.0%

• Indian or African Asian 4.7%

• African Caribbean 5.3%

• All ethnic minorities 5.7%

• All South Asians 6.2%

• Pakistani or Bangladeshi 8.9%

Diabetes and Ethnicity


[Accessed June 2018]

2. Oldroyd, J. Banerjee, M. Heald, A. & Cruickshank, K. (2005) Diabetes and Ethnic Minorities Postgraduate Medical Journal 85: 486-490


• Diabetes and age: You’re more at risk if you’re white and over 40 or over 25 if you’re African-Caribbean, Black African, or South Asian.1

• Diabetes runs in families: You’re two to six times more likely to get Type 2 diabetes if you have a parent, brother, sister or child with diabetes.1

• High blood pressure: If you’ve ever had high blood pressure.1

• Overweight: Especially if you’re large around the middle.1

• Polycystic Ovarian Syndrome

• Ethnicity: 2 to 4 times more likely in people of South Asian descent and African-Caribbean or Black African descent.1

• Mental health: Schizophrenia, bipolar illness or depression, or if you are receiving treatment with antipsychotic medication.1

Risk Factors for Diabetes

1. Diabetes UK (2017) Diabetes Risk Factors Available from: https://www.diabetes.org.uk/Preventing-Type-2-diabetes/Diabetes-risk-factors/ [Accessed June 2018]

https://www.diabetes.org.uk/Preventing-Type-2-diabetes/Diabetes-risk-factors/

• Schizophrenia is associated with relatively high rates of insulin resistance and diabetes, an observation that predates the discovery and widespread use of antipsychotics.1

• Schizophrenia appears to be an independent risk factor for diabetes, and many individuals have a family history of diabetes.2 A genetic predisposition to diabetes appears to be unmasked by the many poor health behaviours associated with schizophrenia, including an unhealthy diet, a lack of exercise and a tendency to smoke.2

• All patients receiving antipsychotic therapy should be assessed for impaired glucose tolerance or diabetes at the start of treatment.3

• Checks should be made at the 12-week follow-up visit and every 6 months for patients with no change in initial values.3

• More frequent assessments are required for patients with significant risk factors for diabetes (overweight, Asian/African ethnicity etc.).3

Schizophrenia and Diabetes


2. Gough, S. & Peveler. R. (2004) Diabetes and its prevention: pragmatic solutions for people with schizophrenia British Journal of Psychiatry Supplement 47: S106-S111

3. Barnett et al. (2007) Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. Journal of Psychopharmacology 21: 357-73

Antipsychotics – risk of diabetes and impaired glucose tolerance1

Adapted from Table 1.30, pg 126. Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell.

Clozapine Olanzapine

QuetiapineRisperidone

Aripiprazole

High-potency

FGAs e.g.

Haloperidol

High Risk

Moderate Risk

Low Risk

Minimal Risk

People with Type 1 Diabetes

1. Diabetes UK (2016) What is Type 1 diabetes? Available from: https://www.diabetes.org.uk/Upload/Guide%20to%20diabetes/What-causes-T1-in-pictures.pdf [Accessed

February 2017].

Carbohydrate1

Glucose1

Bloodstream1

Glucose can’t

enter cells1

No insulin1 Leads to symptoms

like:1

• thirst

• needing to pass

urine often

• tiredness

• weight loss

Normally, cells in our pancreas

produce insulin.1 But in Type 1

diabetes, an autoimmune response

means the body destroys its own

insulin-producing cells.1

Cells need

glucose to

survive1

https://www.diabetes.org.uk/Upload/Guide to diabetes/What-causes-T1-in-pictures.pdf

People with Type 2 Diabetes

Carbohydrate1

Glucose1

Bloodstream1

Glucose can’t

enter cells1

Not enough insulin2Leads to symptoms

like:1

• thirst

• needing to pass

urine often

• tiredness

• weight loss

In Type 2 diabetes, the insulin-producing

cells in the pancreas are unable to produce

enough insulin, or when the insulin is

produced it does not work properly (insulin

resistance).2

Cells need

glucose to

survive.1

1. Diabetes UK (2016) What is Type 1 diabetes? Available from: https://www.diabetes.org.uk/Upload/Guide%20to%20diabetes/What-causes-T1-in-pictures.pdf [Accessed

February 2017]

2. Diabetes UK (2017) What is Type 2 diabetes? Available from: https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-2-Diabetes/ [Accessed June 2018].

https://www.diabetes.org.uk/Upload/Guide to diabetes/What-causes-T1-in-pictures.pdf

https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-2-Diabetes/

How does obesity cause Type 2 diabetes?

• It is a well known fact that if you are overweight or obese, you are at greater risk of developing Type 2 diabetes, particularly if you have excess weight around your tummy (abdomen).1

Inflammatory response

• Studies suggest that abdominal fat causes fat cells to release ‘pro-inflammatory’ chemicals, which can make the body less sensitive to the insulin it produces by disrupting the function of insulin responsive cells and their ability to respond to insulin.1

• This is known as insulin resistance - a major trigger for Type 2 diabetes.1

Obesity and Type 2 Diabetes

1. Diabetes.co.uk (2017) Diabetes and Obesity [Internet] Available from: https://www.diabetes.co.uk/diabetes-and-obesity.html [Accessed June 2018]

Video: Diabetes.co.uk (2012) Diabetes and Obesity [Internet] Available from: https://www.youtube.com/watch?v=jT5KmS_absk [Accessed June 2018]

View this video here:

https://www.youtube.com/watch?v=j

T5KmS_absk

https://www.diabetes.co.uk/diabetes-and-obesity.html

https://www.youtube.com/watch?v=jT5KmS_absk

https://www.youtube.com/watch?v=jT5KmS_absk

• In Type 1 diabetes, the body produces very little insulin and so people with Type 1 diabetes have to try their best to perform the job of their pancreas.1

• Taking injections at the same time of day, where possible, is a good place to start. It is particularly important to take long-term insulin at the same time(s) each day.1

• Test regularly; for example, asking questions about why the patient went into a hypo such as:1

• Did you take too much insulin for lunch?

• Did you exercise harder than usual?

• Were you already low before the exercise?

• Did you have low sugar levels before lunch?

Controlling Type 1 Diabetes

1. Diabetes.co.uk (2017) Controlling Type 1 Diabetes http://www.diabetes.co.uk/controlling-type1-diabetes.html [Accessed June 2018].

http://www.diabetes.co.uk/controlling-type1-diabetes.html

HbA1c testing:

• An HbA1c result gives a good guide to how well blood glucose levels are controlled over a period of 2 to 3 months leading up to the test.1

In adults with Type 2 diabetes measure HbA1c levels at:2

• 3-6 monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy

• 6-monthly intervals once the HbA1c level and blood glucose lowering therapy are stable.

In adults with Type 2 diabetes support the person to aim for a HbA1c level of:2

• 48 mmol/mol (6.5%) if their diabetes is managed either by lifestyle/ diet, or by lifestyle/ diet combined with a single drug not associated with hypoglycaemia.

• 53 mmol/mol (7.0%) if they are on a drug associated with hypoglycaemia.

Controlling Type 2 Diabetes

1. Diabetes.co.uk (2017) Controlling Type 2 Diabetes http://www.diabetes.co.uk/controlling-type2-diabetes.html [Accessed June 2018]

2. National Institute for Health and Care Excellence (2017) Type 2 diabetes in adults: management. NICE guideline [NG28] [Internet] Available from:

https://www.nice.org.uk/guidance/ng28 [Accessed June 2018]

http://www.diabetes.co.uk/controlling-type2-diabetes.html


NICE recommended target blood glucose level ranges to minimise risk of long-term problems:

Management of Diabetes

1. National Institute for Health and Care Excellence (2016) Type 1 diabetes in adults: diagnosis and management. NICE guideline [NG17] [Internet] Available from:




Target levels by

Type

Before breakfast

‘fasting’ level

Before meals at

other times of day

>90 mins after

meals

Type 1 diabetes1 5 to 7 mmol/L 4 to 7 mmol/L 5 to 9 mmol/L

Type 2 diabetes2 Do not routinely offer self-monitoring of blood glucose levels unless: the

person is on insulin, evidence of hypoglycaemic episodes, the person is on

oral medication that may increase risk of hypoglycaemia or the person is

pregnant.



HbA1c as an indicator of Diabetes Control

Image adapted from: Diabetes.co.uk (2017) Guide to HbA1c http://www.diabetes.co.uk/what-is-hba1c.html [Accessed June 2018]

http://www.diabetes.co.uk/what-is-hba1c.html

• Going to the toilet often

• Extreme thirst

• Extreme tiredness

• Weight loss

• Genital itching and thrush

• Cuts and wounds take longer to heal

• Blurred vision

Signs and Symptoms1

1. Diabetes UK (2017) Diabetes: The Basics, What are the signs and symptoms of diabetes? Available from: https://www.diabetes.org.uk/Diabetes-the-basics/Diabetes-

Symptoms/ [Accessed June 2018]

https://www.diabetes.org.uk/Diabetes-the-basics/Diabetes-Symptoms/

Impact of Diabetes



Diabetes Impact1

Cardiovascular

Disease

Cardiovascular disease is a major cause of death and disability in people with

diabetes, accounting for 44% of fatalities in people with Type 1 diabetes and 52%

in people with Type 2.

Kidney Disease Kidney disease accounts for 21% of deaths in Type 1 diabetes and 11% of deaths

in Type 2.

Eye Disease Within 20 years of diagnosis nearly all people with Type 1 and almost 60% of

people with Type 2 diabetes have some degree of retinopathy.

Amputation Diabetes is the most common cause of lower limb amputations and around

7,400 leg, toe or foot amputations happen each year in England alone. People

with diabetes are estimated to be up to 30 times more likely to have an

amputation compared with the general population.


Impact of Diabetes



Diabetes Impact1

Depression Most studies suggest that people with diabetes are twice as likely to suffer an

episode of depression. People who suffer with depression however are very likely

to develop Type 2 diabetes – with a 60% increased risk.

Neuropathy Neuropathies (or nerve damage) may affect up to 50% of patients with diabetes.

Sexual Dysfunction In 2009, a world literature review found that the reported prevalence of erectile

dysfunction was between 35% and 90% among men with diabetes. One study

found that 27% of women with Type 1 diabetes reported sexual dysfunction.

Dementia People with Type 2 diabetes are at a 1.5– 2.5 fold increased risk of dementia.


Case Study 3

Jahan, age 42

Jahan isn’t complaining of anything at present, but during your initial assessment you

record the following:

Lightheaded, dizzy, possibly faint, unstable, nausea and chest discomfort – may dismiss

the symptoms as being normal.

Case Study 3

• Jahan isn’t complaining of anything at present, but during your initial

assessment you record the following: Lightheaded, dizzy, possibly faint,

unstable, nausea and chest discomfort - may dismiss the symptoms as normal.

Treatment history and Presentation Observations

Age 42

Temp 36.9°C

BP systolic 170mmHg

BP diastolic 95mmHg

Pulse 98

Respirations 16

BMI 32

O2 Sats 98%

AVPU Alert

Blood Sugar 15What other actions should you take long-term?




Jahan isn’t complaining of anything at present, but during your initial assessment

you record the following: Lightheaded, dizzy, possibly faint, unstable, nausea and

chest discomfort - may normalise symptoms.


Perform ECG at a yearly check-up. Consider measuring QTc within a week of

achieving a therapeutic dose of a moderate/ high-risk antipsychotic.1

What other actions should you take long-term?

Possible untreated hypertension and diabetes, hits the metabolic syndrome criteria,

acute coronary syndrome (ACS) and Cushing’s syndrome. In the absence of

conclusive data, assume all antipsychotics are linked to sudden cardiac death.1


Prescribe the lowest dose possible and avoid polypharmacy/ metabolic

interactions. Perform ECG on admission.1

What are your immediate actions likely to be?

Observations

Age 42

Temp 36.9°C

BP systolic 170mmHg

BP diastolic 95mmHg

Pulse 98

Respirations 16

BMI 32

O2 Sats 98%

AVPU Alert

Blood Sugar 15


Metabolic Syndrome

According to the most recent IDF definition, for a person to be defined as having metabolic syndrome they

must have: Central obesity (defined as waist circumference with ethnicity specific values) plus any two of the

following four factors:

Raised triglycerides ≥ 150 mg/dL (1.7 mmol/L)

or specific treatment for this lipid abnormality

Reduced HDL cholesterol < 40 mg/dL (1.03 mmol/L) in males

< 50 mg/dL (1.29 mmol/L) in females

or specific treatment for this lipid abnormality

Raised blood pressure systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg

or treatment of previously diagnosed hypertension

Raised fasting plasma glucose (FPG) ≥ 100 mg/dL (5.6 mmol/L), or previously diagnosed type 2

diabetes. If above 5.6 mmol/L or 100 mg/dL, Oral Glucose Tolerance

Test (OGTT) is strongly recommended, but is not necessary to define

presence of the syndrome.

Adapted from Table 2, p.81 Han, T.S. & Lean, M.E.J. (2015) Metabolic syndrome. Medicine. 43(2); 80-87.

• The measurement of waist circumference provides information on the distribution of body fat.1

• When measuring:

• Ensure that the tape is an adequate length

• Place the tape in the correct position

• It may be easier to get the patient to do it themselves!

Waist Circumference

1. Lean, M.E.J, Han T.S, Seidell J.C (1998) Impairment of health and quality of life in people with large waist circumference. The Lancet .351: 853–6.

Image: Westmeath Examiner (2015) Whelehans pharmacys aisling murray discusses weight bmi waist circumference. Available from:

http://www.westmeathexaminer.ie/news/sponsorededitorial/articles/2015/02/10/4035640-whelehans-pharmacys-aisling-murray-discusses-weight-bmi--waist-circumference/


http://www.westmeathexaminer.ie/news/sponsorededitorial/articles/2015/02/10/4035640-whelehans-pharmacys-aisling-murray-discusses-weight-bmi--waist-circumference/

Ethnicity specific waist circumference values for obesity1

Ethnic group Waist circumference (cm)

Europids* Male ≥ 94

Female ≥ 80

South Asians

Chinese, Malaysians and Asian-Indians

Male ≥ 90

Female ≥ 80

Chinese Male ≥ 90

Female ≥ 80

Japanese Male ≥ 85

Female ≥ 90

South and Central Americans Use South Asian recommendations*

Sub-Saharan Africans Use European recommendations*

Eastern Mediterranean and Middle Eastern populations Use European recommendations*

*Until more specific data are available.

1. International Diabetes Federation (2006) The IDF consensus worldwide definition of the metabolic syndrome Available from: https://www.idf.org/e-library/consensus-

statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html [Accessed June 2018].

https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html

What is a healthy BMI range?

BMI =weight(𝑘𝑔)

height m 2

Classification of weight: BMI cut-off points for adults

1. National Institute for Health and Care Excellence (2014) Obesity: identification, assessment and management [CG189] [Internet] Available from:

https://www.nice.org.uk/guidance/cg189/ifp/chapter/obesity-and-being-overweight [Accessed June 2018].

Classification1 BMI (kg/m2)1

Underweight < 18.50

Healthy weight 18.50 – 24.99

Overweight ≥ 25.00- 29.99

Obesity I ≥ 30.00- 34.99

Obesity II ≥ 35.00- 39.99

Obesity III ≥40

https://www.nice.org.uk/guidance/cg189/ifp/chapter/obesity-and-being-overweight

• For patients with:

• BMI < 18.50 or ≥ 25.001 and/or

• Waist circumference ≥ 80 cm (female)/ ≥ 94 cm (male)1

• Any degree of overweight in high risk groups (diabetes, smoker, and other CVD risk factors)2

• Support and exchange information on diet (i.e. meal planning) and exercise.1

• Referral to a local weight/ exercise management programme may be required.1

• Consider medication review.1

• For overweight patients aim for 10% weight loss in 3 months to achieve significant health benefits.2

Management of underweight, overweight and obese patients

1. Barnett et al. (2007) Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. Journal of Psychopharmacology. 21: 357-73.

2. National Obesity Forum (2010) Guidelines on management of adult obesity and overweight in primary care Available from:

http://www.nationalobesityforum.org.uk/images/stories/W_M_guidelines/NOF%20Adult%20Guidelines%20temporary%20revision%20June%202%202010.pdf [Accessed June

2018].

http://www.nationalobesityforum.org.uk/images/stories/W_M_guidelines/NOF Adult Guidelines temporary revision June 2 2010.pdf

Drugs that contribute to weight gain

High risk of weight gain Clozapine

Olanzapine

Moderate risk of weight gain Chlorpromazine

Flupentixol

Quetiapine

Risperidone

Paliperidone

Low risk of weight gain Amisulpride

Aripiprazole

Haloperidol

Loxapine

Sulpiride

Trifluoperazine

Zuclopenthixol

Adapted from Table 1.8, p.39, Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell.

Sedation


Key

+++ High incidence/

severity

++ moderate

+ low

- very low

Drug Sedation incidence

Amisulpride -

Aripiprazole -

Clozapine +++

Flupentixol +

Fluphenazine +

Haloperidol +

Lurasidone +

Olanzapine ++

Paliperidone +

Quetiapine ++

Risperidone +

Zuclopenthixol ++

Triglycerides

1. MedicineNet.com (2016) Medical Definition of Triglycerides Available from: http://www.medicinenet.com/script/main/art.asp?articlekey=8880 [Accessed June 2018]

2. MedicineNet.com (2016) Lowering your Cholesterol Levels Slideshow, Slide 6 Available from: http://www.medicinenet.com/cholesterol_levels_pictures_slideshow/article.htm [Accessed

June 2018]

Video: Mayo Clinic (2010) Lowering Triglycerides –Mayo Clinic [Internet]. Available from: https://www.youtube.com/watch?v=GD0ubOUoXQs [Accessed June 2018]

Picture: MedicineNet.com (2016) Lowering your Cholesterol Levels Slideshow: Slide 2 [Internet]. Available from: http://www.medicinenet.com/cholesterol_levels_pictures_slideshow/article.htm


• Triglycerides are the major form of fat stored by the body.1

• They consist of 3 molecules of fatty acid combined with a molecule of the alcohol glycerol and serve as the backbone of many types of lipids (fats).1

• Triglycerides come from the food we eat as well as from being produced by the body.1

• Triglyceride levels are influenced by recent fat and alcohol intake, and should be measured after fasting for at least 12 hours.1 A period of abstinence from alcohol is advised before testing for triglycerides.1

• High levels can raise the risk for heart disease and metabolic syndrome, which also is a risk factor for diabetes, and stroke.2

• Obesity, diabetes, smoking, alcohol abuse, and lack of exercise can all lead to high triglyceride levels.2

View this video here:

https://www.youtube.com/watch?v=

GD0ubOUoXQs

http://www.medicinenet.com/script/main/art.asp?articlekey=8880

http://www.medicinenet.com/cholesterol_levels_pictures_slideshow/article.htm

https://www.youtube.com/watch?v=GD0ubOUoXQs


http://www.google.co.uk/url?url=http://healthyceleb.com/cholesterol-diet-bring-cholesterol-level-control-foods/15298&rct=j&frm=1&q=&esrc=s&sa=U&ved=0CDAQwW4wDWoVChMI9IDau-q3xwIVk1iSCh3BvwDp&sig2=HvK3Vgvtl9_IGJeMLT7fCg&usg=AFQjCNEhqr9F_i1Q_bm8qo-l4ycBaIbglQ

https://www.youtube.com/watch?v=GD0ubOUoXQs

• HDL cholesterol is considered "good" cholesterol because it works to keep the LDL, or "bad" cholesterol from building up in the arteries.1

• The higher the HDL, the better.1

• Measuring total and HDL cholesterol can give an estimate of cardiovascular disease (CVD) risk.2

• NICE guidelines for assessing CVD recommend to use clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder, rather than the use of strict lipid cut-off values alone.2

High-density Lipoprotein (HDL) vs Low-Density Lipoprotein (LDL) Cholesterol

1. MedicineNet.com (2016) Lowering your Cholesterol Levels Slideshow, Slide 4 Available from: http://www.medicinenet.com/cholesterol_levels_pictures_slideshow/article.htm


2. National Institute for Health and Care Excellence (2016) Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical guideline [CG181]

[Internet] Available from: https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations [Accessed June 2018]


https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations

• Before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile. This should include measurement of total cholesterol, HDL cholesterol, non-HDL cholesterol and triglyceride concentrations. A fasting sample is not needed.1

Lipid measurement and referral for cardiovascular disease (CVD)

1. National Institute for Health and Care Excellence (2016) Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical guideline [CG181]

[Internet] Available from: https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations [Accessed June 2018]

Lipid values1 Family history/ clinical profile1 Investigations and risk1

Total cholesterol concentration:

>7.5 mmol/litre

Family history of premature

coronary heart disease

Consider possibility of familial hypercholesterolaemia and

investigate

Total cholesterol concentration:

>9.0 mmol/litre

Non-HDL cholesterol

concentration: >7.5 mmol/litre

Absence of first-degree family

history of premature coronary heart

disease

Arrange for specialist assessment

Triglyceride concentration:

>20 mmol/litre

Not a result of excess alcohol or

poor glycaemic control

Refer for urgent specialist review


10 - 20 mmol/litre

Repeat the measurement with a fasting test (after an interval of 5

days, but within 2 weeks) review for potential secondary causes of

hyperlipidaemia and

seek specialist advice if the triglyceride concentration remains

above 10 mmol/litre


4.5 – 9.9 mmol/litre

Be aware that the CVD risk may be

underestimated by risk assessment

tools

Optimise the management of other CVD risk factors present and

seek specialist advice if non-HDL cholesterol concentration is more

than 7.5 mmol/litre.

https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations

Blood Pressure and Pulse

In what range should a normal blood pressure be?

• Hypertension is a significant risk factor for cardiovascular disease.1

• For all people with hypertension use a formal estimation of cardiovascular risk, and offer to:

• Test urine for presence of protein

• Test blood for plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol

• Examine the fundi for the presence of hypertensive retinopathy

• Perform a 12-lead electrocardiograph.2

• For patients with blood pressure > 140/90 mmHg exchange information on weight loss/ exercise (if overweight), improved diet and reduction in alcohol intake.1

Blood Pressure (BP)

1. Williams et al. (2004) Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. Journal of Human

Hypertension 18:139-85.

2. National Institute for Health and Care Excellence (2016) Hypertension in adults: diagnosis and management. NICE clinical guideline [CG127] [Internet] Available from:

https://www.nice.org.uk/guidance/cg127 [Accessed June 2018]

Target BP by patient group2 <80 years2 >80 years2

Treated hypertension > 140/90 mmHg > 150/90 mmHg

Treated hypertension and people who have a

‘white coat effect’ or monitor their BP at home.

> 135/85 mmHg > 145/85 mmHg


Target Blood Pressure (BP) for Type 2 diabetes



BP measurement1 Action1

> 130/80 mmHgand there is kidney,

eye or cerebrovascular

damage.

Repeat measurement after 2 months and if confirmed consistent:

Provide lifestyle advice and if this doesn’t reduce BP:

Add medications

Monitor every 1-2 months and intensify therapy if still not reduced.

> 140/80 mmHg Repeat measurement after 2 months and if confirmed consistent:

Provide lifestyle advice and if this doesn’t reduce BP:

Add medications

Monitor every 1-2 months and intensify therapy if still not reduced.

> 150/90 mmHg Repeat measurement after 1 month

• Measure BP at least annually in an adult with Type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventative lifestyle advice.1

• Target BP for Type 2 diabetes is:

consistently below 140/80 mmHg or below 130/80 mmHg if there is kidney, eye or cerebrovascular damage.1


To measure the pulse in someone’s wrist:1

• Hold arm straight, with the palm of the hand facing upwards

• Place index and middle finger on the wrist at the base of their thumb – don’t use your thumb as it has its own pulse

• Press the skin lightly until feel the pulse, or move your fingers around if you can’t find it

• Count the number of beats for a full 60 seconds, or 30 seconds and multiply by 2.

• Most adults have a resting heart rate between 60 – 100 beats per minute.1

Pulse Rate

1. NHS Choices (2018) Common health questions: How do I check my pulse? [Internet]. Available from: https://www.nhs.uk/chq/Pages/2024.aspx [Accessed June 2018].

https://www.nhs.uk/chq/Pages/2024.aspx

Many psychotropic drugs are associated with ECG changes and some are causally linked to serious ventricular arrhythmia and sudden cardiac death. 1 Specifically they are linked to prolongation of the cardiac QT interval (QTc), a risk factor for ventricular arrhythmia, which is often fatal.1

Table 1: Effects of antipsychotics on QTc1

ECG changes: QTc prolongation

1. Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell. pg.112.

Table 1: Adapted from Table 1.24, p.114, Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell.

No effect Low effect Moderate effect High effect Unknown effect

Brexpiprazole*

Cariprazine*

Lurasidone

Aripiprazole†

Asenapine

Clozapine

Flupentixol

Fluphenazine

Loxapine

Perphenazine

Prochlorperazine

Olanzapine‡

Paliperidone

Risperidone

Sulpiride

Amisulpride§

Chlorpromazine

Haloperidol

Iloperidone

Levomepromazine

Melperone

Quetiapine

Ziprasidone

Any intravenous antipsychotic

Pimozide

Sertindole

Any drug or combination of

drugs used in doses exceeding

recommended maximum

Pipothiazine

Trifluoperazine

Zuclopenthixol

* Limited clinical experience (association with QT prolongation may emerge). † One case of torsades de pointes (TDP) reported, two cases

of QT prolongation and an association TDP found in database study. Recent data suggest aripiprazole causes QTc prolongation of around

8ms. Aripiprazole may increase QT dispersion. ‡ Isolated cases of QTc prolongation and has effects on cardiac ion channel, Ikr, other data

suggest no effect on QTc. § TDP common in overdose; strong association with TDP in clinical doses.

Case Study 4

Suzie, age 20

During the medication round you notice Suzie appears slightly unsteady on her feet and

slightly confused after she was admitted 6 hours ago. You record the following:

Dizzy, lower level of consciousness, lethargic, headache, Suzie has not passed urine or

only small amounts.

Case Study 4

• During the medication round you notice Suzie appears slightly unsteady on her

feet and slightly confused after she was admitted 6 hours ago.

• Dizzy, lower level of consciousness, lethargic, headache, not passed urine.


What next steps should you take?



Observations

Age 20

Temp 38°C

BP systolic 140mmHg

BP diastolic 90mmHg

Pulse 119

Respirations 20

BMI 29

O2 Sats 100%

AVPU Reacts to

Voice

Blood Sugar 5


• During the medication round you notice Suzie appears slightly unsteady on her

feet and slightly confused after she was admitted 6 hours ago.

• Dizzy, lower level of consciousness, lethargic, headache, not passed urine.


Seek further medical advice if the symptoms don’t improve with treatment and

call 999 or go to A&E if signs of serious dehydration begin, as this will need

urgent treatment.1

What next steps should you take?

Moderate to Severe Dehydration, Mild Pyrexia


Introduce fluids: ask them to keep taking small sips and gradually drink more if

they can. They should drink enough so that their pee is a pale clear colour.1


Observations

Age 20

Temp 38°C

BP systolic 140mmHg

BP diastolic 90mmHg

Pulse 119

Respirations 20

BMI 29

O2 Sats 100%

AVPU Reacts to

Voice

Blood Sugar 5

1. NHS Choices (2017) Dehydration. Available from: https://www.nhs.uk/conditions/dehydration/#symptoms [Accessed June 2018]

https://www.nhs.uk/conditions/dehydration/#symptoms

What are the early warning signs?

Dehydration

• Dehydration means the body loses more fluids than are taken in. If it isn’t treated it can get worse and become a serious problem.1

• Symptoms include:1

• Feeling thirsty

• Dark yellow and strong smelling pee

• Feeling dizzy or lightheaded

• Feeling tired

• Dry mouth, lips and eyes

• Peeing little and fewer than 4 times a day

Symptoms of Dehydration

1. NHS Choices (2017) Dehydration. Available from: https://www.nhs.uk/conditions/dehydration/#symptoms [Accessed June 2018]


Symptoms of severe dehydration:1

• Feeling unusually tired

• Confused and disorientated

• Dizziness when standing up that doesn't go away

• Not passing urine for eight hours

• A weak pulse

• A rapid pulse

• Fits (seizures)

Serious Dehydration

1. NHS Choices (2017) Dehydration. Available from: https://www.nhs.uk/conditions/dehydration/#symptoms [Accessed June 2018].


• These can be signs of serious dehydration which need urgent treatment.1

• Call 999 or go to A&E.1

Treatment



• Babies, children and the elderly are more at risk of dehydration.1

• Dehydration can happen more easily if the person has: diabetes, vomiting/ diarrhoea, heatstroke, drunk excessive alcohol, sweated too much after exercising, a high temperature of 38 degrees or more, taken diuretics.1

• To reduce the risk, drink fluids when any symptoms appear – keep taking small sips. The person should drink enough during the day so that their pee is a pale clear colour.1

• To help people drink:1

• Make sure they drink during mealtimes

• Make drinking a social thing, like “having a cup of tea”

• Offer them food with high water content – soups, ice cream, jelly, fruits like melon.

Reducing the risk of dehydration



Dehydration can occur at any time of an admission

Image: Voth, L (2013) Got Water? [Internet]. Available from: http://simplyfantasticbooks.com/2013/07/18/got-water/ [Accessed June 2018].

http://simplyfantasticbooks.com/2013/07/18/got-water/

OTHER PHYSICAL HEALTH ISSUES TO BE AWARE OF

Hyperprolactinaemia

• Dopamine inhibits prolactin release and so dopamine antagonists can be expected to increase prolactin plasma levels. The degree of prolactin elevation is probably dose-related, and for antipsychotic medications the threshold activity (D₂ occupancy) for increased prolactin is very close to that of therapeutic efficacy.1

• Hyperprolactinaemia is often superficially asymptomatic. Nonetheless, persistent elevation of plasma prolactin is associated with following symptoms: sexual dysfunction, menstrual disturbances, breast growth and galactorrhoea and may include delusions of pregnancy. Long-term adverse consequences are reductions in bone mineral density and a possible increase in the risk of breast cancer.1

• Prolactin-elevating drugs with high risk should, if possible, be avoided in the following patient groups:

- Patients under 25 years of age (i.e. before peak bone mass)

- Patients with osteoporosis

- Patients with a history of hormone-dependent breast cancer

- Young women1

Hyperprolactinaemia


Effects of antipsychotic medication on prolactin concentration


Prolactin-sparing

(prolactin increase very rare)

Prolactin-elevating

(low risk; minor changes only)

Prolactin-elevating

(high risk; major changes)

Aripiprazole Lurasidone Amisulpride

Asenapine Olanzapine Paliperidone

Brexpiprazole* Ziprasidone Risperidone

Cariprazine Sulpiride

Clozapine FGAs (e.g. haloperidol and

chlorpromazine)

Iloperidone*

Quetiapine

* Not available in the EU at the time of writing.

FGA, first-generation antipsychotic.

• Women – ask about changes in menstruation, libido & if they have milk coming out of their breasts.

• Men – ask about libido, erectile and ejaculatory function.

• If any symptoms then test prolactin levels.

• Measure prolactin levels by a morning, fasting, pre-medication sample.

Do nothing, just monitor1 How to manage raised prolactin?1

• Reduce dose of current antipsychotic.

• Introduce a dopamine agonist or

oestrogen for women.

• Switch to a relatively prolactin-sparing

antipsychotic.

Management of raised prolactin

1. Walters, J. & Jones, I. (2008) Clinical questions and uncertainty – prolactin measurement in patients with schizophrenia and bipolar disorder. Journal of Psychopharmacology,

22:82-89.

• What are Liver Function Tests?

• Which antipsychotics can cause raised/ abnormal LFTs and how often should checks be carried out?

Liver Function Test

• Most tests measure hepatocellular damage rather than function, so they are rather misnamed.1

• True liver function tests (LFTs) are those that measure synthesis of proteins made by the liver (albumin, clotting factors) or the liver's capacity to metabolise drugs.1

Table 1: Blood tests for liver function2

Liver function tests (LFTs)

1. Lowth M. (2014) Gastroenterology: abnormal liver function tests. [Internet]. Available from: https://patient.info/doctor/abnormal-liver-function-tests#nav-0


2. Liver Doctor (2018) Liver function tests: blood tests for liver function. [Internet]. Available from: http://www.liverdoctor.com/liver/liver-function-tests/


Standard LFTs Normal Range Abnormal Range:

Blood proteins: Serum albumin 38 to 55 g/L Falling levels indicate severity of chronic liver disease.

Blood proteins: Globulin protein 20 to 32 g/L High levels indicate excessive inflammation in the liver

and/or immune system. Very high levels may be seen in

some cancers.

Total Bilirubin 0 to 20 umol/L This measures the amount of bile pigment in the blood.

Elevated levels could indicate jaundice.

Liver Enzymes: Aspartate aminotransferase (AST) 0 to 45 U/L Not liver specific, elevated in heart and muscle diseases too.

Liver Enzymes: Alanine aminotransferase (ALT) 0 to 45 U/L Specific to liver damage.

Liver Enzymes: Alkaline phosphatase (ALP) 30 to 120 U/L Elevated in many different diseases.

Liver Enzymes: Gamma glutamyl transpeptidase

(GGT)

0 to 45 U/L Elevated in those who use alcohol or other liver-toxic

substances to excess.

https://patient.info/doctor/abnormal-liver-function-tests#nav-0

http://www.liverdoctor.com/liver/liver-function-tests/

• One-third of patients who are prescribed antipsychotic medication have at least one abnormal LFT, and in 4% at least one LFT is elevated three times above the upper limit of normal.1

• Transaminases are most often affected and this generally occurs within 1-6 weeks of treatment initiation.1

• Only rarely does clinically significant hepatic damage result.1

• Note that many patients with chronic liver disease are asymptomatic or have fluctuating clinical symptoms. Always consider the clinical function rather than adhere to rigid rules involving LFTs.1

Antipsychotic medication in hepatic impairment

1. Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell. pg.38, 635-636.

Clozapine and chlorpromazine are associated with hepatic failure.

Drugs for which monitoring is not required: amisulpride, sulpiride.1

• When interpreting LFTs remember that absolute values are a poor indicator of disease severity.1

• Suggested frequency of LFTs is at baseline then yearly as part of a routine physical health check and to detect chronic antipsychotic induced changes (rare).1

• If tests are slightly abnormal (less than twice upper limit):2

• Repeat tests.

• Check alcohol intake, ask them to abstain and repeat tests.

• Exchange information on diabetes control and weight loss if appropriate.

• Refer if tests abnormal for > 6 months.

• If tests are very abnormal:2

• Organise further blood tests and imaging.

• If you suspect the cause may be malignancy then an urgent cancer referral should be made.

• Consider urgent referral for hospital admission if a patient is unwell (e.g. jaundice or sepsis).

Management of abnormal LFTs

1. Taylor, D., Barnes, M. & Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry. 13th Ed. Chichester: Wiley Blackwell. pg.38, 642.

2. Lowth M. (2014) Gastroenterology: abnormal liver function tests. [Internet]. Available from: https://patient.info/doctor/abnormal-liver-function-tests#nav-

0 [Accessed June 2018].

https://patient.info/doctor/abnormal-liver-function-tests#nav-0

Alcohol intake

• The chief medial officers of the UK warn that drinking any level of alcohol increases the risk of a range of cancers.1

• The guidelines state that it is safest not to regularly drink more than 14 units per week, which applies to both adult men and women.1

• If you do drink as much as 14 units per week, it is best to spread this evenly over three days or more.1

• The new proposed guidelines also look at the potential risks of single drinking sessions, which can include accidents resulting in injury, misjudging risky situations and losing self-control.1

• Offer recommendations on sensible daily alcohol intake.

Alcohol intake

1. Department of Health and Social Care (2016) New alcohol guidelines show increased risk of cancer. [Internet] Available from:

https://www.gov.uk/government/news/new-alcohol-guidelines-show-increased-risk-of-cancer [Accessed June 2018].

https://www.gov.uk/government/news/new-alcohol-guidelines-show-increased-risk-of-cancer

Alcohol guidance

Adapted from Public Health England (2017) Guidance: Alcohol use screening tests. [Internet]. Available at:

https://www.gov.uk/government/publications/alcohol-use-screening-tests [Accessed June 2018].

https://www.gov.uk/government/publications/alcohol-use-screening-tests

Diet

• Dietary habits can have an adverse effect on schizophrenia outcome and the prevalence of depression.1

• A higher dietary intake of refined sugar and dairy products are associated with a worse outcome in schizophrenia.1

• In order to reduce the risk of obesity, diabetes and coronary heart disease in people with schizophrenia, the importance of a healthy lifestyle, including good dietary practices and sufficient exercise, cannot be overemphasised.1

Diet and schizophrenia

1. Peet M. (2004) International variations in the outcome of schizophrenia and the prevalence of depression in relation to national dietary practices: an

ecological analysis. British Journal of Psychiatry. 184: 404–8.

How will this training affect your practice in the future?

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