Efficacy should drive atypical antipsychotic treatment

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7383.283/a (Published 01 February 2003) Cite this as: BMJ 2003;326:283
  1. Leslie L Citrome (citrome{at}nki.rfmh.org), clinical professor of psychiatry
  1. Nathan S Kline Institute for Psychiatric Research, 140 Old Orangeburg Road, Orangeburg, NY 10962, USA

    EDITOR—Koro et al say that olanzapine is associated with a clinically important and significant increased risk of diabetes.1 To date five other pharmacoepidemiological papers have been published about the possible increase in risk for diabetes in patients receiving atypical antipsychotics.26

    All use a variety of methods and have come up with a variety of conclusions: clozapine poses a higher risk for diabetes for patients younger than 40,2 clozapine, risperidone, olanzapine, and quetiapine are associated with higher rates of diabetes among patients aged 20-34,3 neither clozapine nor risperidone pose a higher risk,4 atypical antipsychotics may pose a higher risk,5 and risperidone poses no additional significant risk as opposed to clozapine and olanzapine.6

    Of these six studies, two have been funded and coauthored by a pharmaceutical manufacturer. 1 6 Two have used the same database. 1 5

    Missing from these analyses are important risk factors such as ethnic group, 1 2 5 6 body mass index, 14 6 family history of diabetes,16 and level of activity.16 These risk factors may overshadow the attributable risk posed by specific atypical antipsychotic exposure itself.

    Concerns about efficacy ought to have the dominant role in selecting treatment. Whether a patient will develop diabetes based only on exposure to specific antipsychotic drugs is not easily predictable, but the consequences of poor control of the symptoms of schizophrenia are obvious.

    Managing risk by routine monitoring of fasting plasma glucose and other measures ought to be done for all patients taking any antipsychotic drug, especially if risk factors are present.


    • Competing interests LC has received honoraria, research support, and consulting fees from Abbott, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, and Pfizer.


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