Wednesday, December 06, 2006

A Silver Bullet?

A trial in the new American Journal of Psychiatry found that adding metformin to a regimen of atypical antipsychotic medications stopped children from continuing to gain weight while taking the atypical antipsychotics. So can we now just shrug off concerns about the skyrocketing use of atypical antipsychotic use among kids? Here’s part of what an accompanying editorial by Towbin had to say:

“The study does not address the long-term safety of metformin treatment or whether weight loss is sustained. This is important because vulnerable children may require metformin treatment as long as they continue to take atypical antipsychotics, typically for symptoms that last many years. Metformin, a relative of pheformin, has long-term side effects that lead to B12 and folate deficiency (7) in up to 30% of chronic users. Fatal lactic acidosis with metformin has been seen in the context of uncompensated congestive heart disease, acute renal insufficiency, and liver disease (8) and may emerge with chronic use of nonsteroidal anti-inflammatory drugs (9). It is reassuring that these conditions are relatively rare in children and adolescents. In addition, the study did not compare pharmacological treatment to specific, targeted treatments for dietary control that combine dietary counseling, exercise, and behavioral intervention, which have been shown to be effective in adults (10, 11). Just as patients in the metformin trial missed doses of medication, behavioral programs also have problems with patients failing to adhere to their diet or exercise schedules on occasion…

Finally, it is noteworthy for our field that such a high proportion of the cohort had diagnoses or symptoms for which there is no clear FDA-approved indication for treatment with atypical antipsychotics (12, 13)17 (44%) of the 39 had "attentional disorders," and seven (18%) had oppositional defiant disorder.

My View: Doubtless, many will take this as a blessing to continue the use of atypicals for everything (including ADHD and oppositional defiant disorder, apparently) now that a “cure” for weight gain has been discovered. Don’t get me wrong – if metformin is really helpful, GREAT! But I’ll await longer-term studies before I jump on this bandwagon.


Alone said...

NEJM study this week showing Glucophage and Avandia were both better than glyburide; Avandia worked slightly longer than Glucophage (about a year) but Avandia came with much more weight gain (15lbs vs a loss of 6 lbs for Glucophage) and edema.

And Glucophage has already been studied as a weight loss agent in non-diabetic, non-antipsychotic using obese teens and middle aged adults-- but the weight loss, again, is about 5-6 lbs.

So it isn't surprising that Glucophage caused weight loss, and I do not think it's effect has any relation to inhibiting the wieght gain of antipsychotics, per se.

The real question, of course, is why anyone would ever do this maneuver. when there are so many other, simpler maneuvers you could do.

P.S. if you take Glucophage, be careful of lactic acidosis (dehydration, NSAIDs, kdiney problems, etc)

CL Psych said...

As always, great comment. I may have to actually stick this one up as its own post, of course giving you proper credit for your writing.