Managing Adverse Effects and Medication Changes in Bipolar Disorder

In this podcast excerpt from Psych Congress Regionals, Saundra Jain, PsyD, adjunct clinical affiliate at The University of Texas at Austin, is joined by Craig Chepke, MD, medical director of Excel Psychiatric Associates, and Rakesh Jain, MD, psychiatrist at Mental Wellness in Austin, Texas, to answer audience questions. In their Regionals session, Drs Chepke and Jain examine transitioning patient medications, managing adverse effects like weight gain, and how strategies like preventive care and medication-assisted interventions can illuminate a path towards holistic well-being in psychiatric practice.

Read the Transcript:

Saundra Jain, PsyD: How are you transitioning patients from olanzapine to the combination olanzapine plus samidorphan? Rakesh, would you take that one? 

Rakesh Jain, MD: Yeah, it's one of the easiest switches in all of psychiatry. But if a person is on, say, 10 or 15 or 20 milligrams of olazanpine and switch to the combination, which is, as you know, the trade name for that Olanzapine samidorphan is Lybalvi.It's an abrupt switch because you're really going from the dose to the dose. All you're doing is you're adding samidorphan that's locked in at 10 milligrams. It's one of the easiest switches that we have in all of psychiatry. I wish all my switches were that simple. 

Dr Saundra Jain: Well, another medication question. Craig, I'm going to toss this one to you, and it's related to weight gain. The question is this. Weight gain on lumateperone was quite a pleasant surprise. How do you explain the low risk of weight gain? 

Craig Chepke, MD: Well, I think we can use some theories. We don't know for sure how any of our medications work, but there's a variety of factors. One is that there was negligible binding affinity to antihistamine, the H1 receptor and histamine effect, negligible to no anti -coinergic effects. Those are often two of the big offenders. Also when you pair antihistamine with the antagonism of the serotonin 2C, that can be potent for weight gain. Again not seen in Lumeteparone. Also another factor is that it only has moderate binding affinity for the dopamine D2 receptor. I think that's underappreciated in terms of its effect on metabolics and weight. There's a delicate interplay between dopamine and insulin. The beta cells of the pancreas are highly enriched with dopamine receptors. And so D2 antagonism in and of itself can be a cause of- just like we can have other endocrine problems like hyperprolactinemia from D2 antagonism then other endocrine problems including insulin dysregulation and sensitivity issues can result.

And so having a lower binding affinity in the moderate affinity range, maybe that could contribute. I think it's a combination of a lot of different things, but that doesn't mean we still shouldn't monitor. You know, those numbers are based off of an aggregate and average of hundreds of patients in clinical trials.

We still need to be weighing our patients every visit. We still need to be checking them at all labs with all of our patients at specified intervals and not let our guard down because, you know, we want to be optimistic, but we also don't want to let the individuals down who could still be at risk for it. 

Dr Saundra Jain: Well, and interestingly, the number of questions specific to weight gain and management, there are a lot of questions. So continuing with that theme and that topic, Rakesh, let me share with you, we have a lot of attendees who want to know what is your go-to strategy in dealing with weight gain and what have you had the most success with in clinical practice? 

Dr Rakesh Jain: Yeah, the single best strategy to use repeatedly is to choose the right medication at the very beginning. So without a doubt, the most effective strategy in preventing a problem is preventing the problem, not treating the problem once it's developed.

So primary prevention, which wasn't a possibility just a few years ago, now is. You just heard Craig give a masterful description of why lumateperone actually in fact does have low weight gain. That's pretty well-demonstrated in short- and long-term studies.

But also Craig offered a very legitimate hypothesis that explains that finding. So what clinicians can do is look at the clinical research and also the receptor binding profile of medications as they're going about choosing their medication. That's the first strategy.

The second strategy is even though we often think that our psychiatrically ill patients simply won't follow our advice on exercise and nutrition, study after study shows if you do it right, which is give them pretty systematic, logical advice on what to do, you can bend the curve. You can bend the curve in the right direction. 

Then finally, there are medication-assisted ways to go. One of them is metformin, but you have to use it before the weight gain comes on. The other one are the GLP -2 agonist medications. Craig, is actually going to give a formal talk on that at Psych Congress, which I'm so looking forward to. But what is emerging, Saundra, is primary, secondary, and tertiary prevention of weight gain with anti-psychotics, is now not just a wish. It is something that we can actually accomplish with very many patients and psychiatric practices.

Dr Saundra Jain: That's very good news.

Craig Chepke, MD, DFAPA, is a board-certified psychiatrist and a Distinguished Fellow of the American Psychiatric Association. Dr Chepke is the medical director of Excel Psychiatric Associates in Huntersville, NC as well as an Adjunct Associate Professor of Psychiatry for Atrium Health. As part of an interdisciplinary treatment team, he employs a person-centered care model to tailor treatments to each individual's needs, integrating traditional pharmacotherapy with psychotherapeutic and physical health and wellness interventions.

Rakesh Jain, MD, MPH, attended medical school at the University of Calcutta in India. He then attended graduate school at the University of Texas School of Public Health in Houston, where he was awarded a “National Institute/Center for Disease Control Competitive Traineeship”. He graduated from the School of Public Health in 1987 with a Masters of Public Health (MPH) degree. Dr Jain served a 3-year residency in Psychiatry at the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston. In addition, Dr Jain completed a postdoctoral fellowship in Research Psychiatry at the University of Texas Mental Sciences Institute, in Houston. He was awarded the “National Research Service Award” for the support of this postdoctoral fellowship.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate in the School of Nursing at The University of Texas at Austin and a psychotherapist in private practice. Dr Jain is a co-creator of the WILD 5 Wellness Program and co-author of a workbook written for those interested in improving their mental wellness titled KickStart30: A Proven 30-Day Mental Wellness Program. She is co-creator of the Psychedelics and Wellness Survey (PAWS), exploring the intersection between psychedelics and wellness. She serves as a member of the Psych Congress Steering Committee, providing direction regarding educational gaps and needs for mental health practitioners, and Sana Symposium, providing psychedelics education for mental health and addiction professionals.