Zyprexa (or Symbyax) Risks in PAR Discussions

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Zyprexa has the virtually the best record for both immediate and long-term control of hypo/manic symptoms of any mood stabilizer (e.g. Tohen), as well as significant antidepressant potential (all by itself, without any antidepressant).Tohen/Vieta  It is a "broad spectrum" medication, capable of addressing agitation, anxiety, severe insomnia, as well as the many aspects of bipolar disorder.  Anyone who's used it much knows how rapidly effective this medication can be. 

However, there is a growing concern about its metabolic effects.  This concern led, in early 2004, to a convening of experts representing the

An 8-member panel from these organizations published their Consensus Statement in early 2004 (full text link).  This document includes an excellent review of the literature on new antipsychotics and their metabolic effects. 

The panel concluded that Zyprexa carries the greatest risk amongst these new generation antipsychotics (with the exception of clozapine, the "original" atypical, which is not widely used due to associated blood dyscrasias and the intensive monitoring therefore required).  They judged that Abilify and Geodon do not cause weight gain or diabetes, based on experience thus far, which is admittedly limited.  Risperidone and Seroquel were found to be intermediate in risk (e.g. see their Table 2). 

According to this Consensus statement, Zyprexa (as well as risperidone and Seroquel) should be used only with the following warnings to patients: :

This medication can cause weight gain and, less commonly, diabetes; especially in those with a family history of diabetes or a personal history of such risk.

It can cause "metabolic syndrome", raising blood pressure, worsening serum lipid profiles, and causing an increase in abdominal fat accumulation. 

They even suggested that patients be informed of the signs of diabetic ketoacidosis (DKA), as follows, from their article:

Rapid onset of:

They recommend that patients starting on Zyprexa should have the following data before starting or at the outset of treatment:

Monitoring at 3 months into treatment, and then at least annually, should include:

With all this, it may be useful to have a single-page handout to supplement your PAR on this medication.  Because such handouts are often not kept or read, you must use this only to augment your presentation.  As always, you should be familiar with the full prescribing information for this medication, and use that to help shape your PAR for each particular patient.