Medication Limitations and Adverse Effects in Bipolar Disorder Treatment

Join Desiree Matthews, PMHNP-BC, from Monarch community mental health center in Charlotte, North Carolina, as she explores the limitations of traditional antipsychotic agents and off-label therapies and uncovers the ongoing challenges of weight gain, sedation, and cardiometabolic disturbances. Nurse Matthews discusses the benefits and downsides of medications like Lumateperone and Olanzapine, and examines how to offer efficacy while minimizing unwanted side effects and adverse events like weight gain and metabolic disturbances.

Find more expert insights on bipolar disorder treatment in our Bipolar Disorder Excellence Forum.

Read the Transcript:

Psych Congress Network: What are the limitations of traditional antipsychotic agents and off-label therapies when treating patients with bipolar disorder?

Desiree Matthews, PMHNP-BC: Despite advancements in the past 10 years with second-generation antipsychotics unfortunately, many of them still come with problems like weight gain, sedation, problems with alterations in lipid, and glucose levels. So cardiometabolic side effects are still a big problem in psychiatry when it comes to our antipsychotic treatments. There are certainly off-label ways that you can manage side effects like weight gain, such as diet, exercise, and lifestyle changes. There are medications like Metformin, topiramate, and now coming to the market, more popular now are your GLP-1 agonists that certainly have approval in type 2 diabetes and obesity. The problem is these are all off-label strategies.

However, in the past few years, we've had advancements in our medications. We have medication like lumateperone, which in both open-label and the short-term studies, showed very minimal weight gain and metabolic disturbances like with lipid panel and glucose. We also have olanzapine samidorphan now.

Many of us know olanzapine, it's efficacious, it works, but a lot of us have steered away from that because of the problem with weight gain and not only weight gain early on, but unfortunately with olanzapine, with many patients, we see this trajectory of increase in weight gain over years and it doesn't stop. But now with olanzapine samidorphan, we do have the option to use that opioid antagonist, samidorphan, layer that on with the efficacious molecule, in this case, olanzapine, and we see efficacy of olanzapine in bipolar disorder, but with about a 50% reduction in weight gain risk. So that certainly now is an option for my patients, and it would make sense for me to start with, that rather than using olanzapine with the risks associated with that.

PCN: What are the cardiometabolic adverse effects that clinicians should be aware of when prescribing medications for patients with BD?

Nurse Matthews: Clinicians should be aware and talk to their patients about common side effects of antipsychotics, like cardiometabolic side effects such as weight gain, increase in lipids, as well as impaired fasting glucose. These are all known side effects, but it's important to understand that we do have newer and novel agents, where we can get efficacy, but without weight gain, without increase in your cholesterol, increase in your A1C. This is really important because we've found surveys, and even maybe in your own clinical practice, you've heard patients, wanting to stop medication because of weight gain. Weight gain can be the number one reason your patients actually stop treatment, and we all know the consequences of non-adherence.

PCN: Any final thoughts or takeaways?

Nurse Matthews: So when it comes to managing bipolar disorder, keep in mind that we have many treatment options now, and your initial treatment option can be a powerful tool when it comes to not only efficacy, but also meeting the patient's expectation in terms of being able to be adherent to medication because of side effects. We really want to make sure that with our medications, patients are doing well, they are recovering, but we also want to be sure that the tolerability is not so bad that they can't continue on with treatment. It's great to have an efficacious medication, but at the end of the day, if patients can't continue on it, they're not going to stay well.

Desiree Matthews, PHMNP-BC, is a board-certified Psychiatric Mental Health Nurse Practitioner. She received her Bachelor's of Nursing from University at Buffalo and her Master's of Nursing at Stony Brook University. She currently resides in Charlotte, NC, and practices at Monarch, a community mental health center providing telepsychiatry services to adult patients. Clinical interests include the treatment of schizophrenia, bipolar disorder, treatment-resistant unipolar depression, and drug-induced movement disorders, including tardive dyskinesia. She has provided faculty expertise and insight into the development of a clinical screener for TD called MIND-TD.