Measure:

Bipolar Disorder: Screening for hyperglycemia when atypical antipsychotic agent prescribed

Summary:

This measure assesses the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who receive at least one screening for hyperglycemia within the initial 16 weeks of treatment.

Clinical Rationale:

Bipolar Disorder, Antipsychotic Medications, & Abnormalities in Glucose Regulation 

• In patients with bipolar disorder abnormalities in glucose regulation that relate to dysregulation in various physiologic systems have been studied and reported (1)
• Treatment with atypical (second generation) antipsychotic medications has been associated with weight gain and resulting impaired glucose metabolism, exacerbation of existing type 1 and type 2 diabetes, new onset of type 2 diabetes and diabetic ketoacidosis (2)
• Case reports and controlled studies indicate that some atypical antipsychotic medications are associated with adverse effects on glucose metabolism independent of adiposity (1)

Monitoring of Glucose Regulation (3)

• Six sets of metabolic monitoring guidelines for persons taking antipsychotic medications are currently recognized (Mount Sinai; Australia; American Diabetes Association-American Psychiatric Association; Belgium; and United Kingdom)
• All monitoring guidelines recommend the Fasting Plasma Glucose as a baseline test
• Although baseline monitoring is indicated as soon as feasible, when possible, monitoring prior to antipsychotic treatment initiation is preferable as the results may influence antipsychotic choice, especially  when elevated risk factors are identified
• When fasting is not feasible to obtain (patient cooperation; cost/time), alternatives considered acceptable were the HbA1c (Mount Sinai; United Kingdom) or the Random Plasma Glucose (Mount Sinai; Australia; United Kingdom); these are not diagnostic for diabetes; however, they can be used as screening tests with follow-up if elevation is found.
• Finger stick glucose testing is not recommended for screening; however, it is considered to be useful in emergency situations to rule out frank hyperglycemia / diabetic ketoacidosis.

Denominator Population:

Patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent

Data Sources:

• Administrative data
• Medical Record

Numerator Population:

Patients who are screened for evidence of hyperglycemia within 16 weeks after initiating treatment with an atypical antipsychotic agent

Data Source:

• Medical Record

Initial Case-finding Guidance:

Patients with a diagnosis involving bipolar disorder
ICD9CM or DSM IV TR: 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80-82; 296.89; or 301.13

STABLE Resource Toolkit:

The STABLE National Coordinating Council has recommended metabolic monitoring when treating with antipsychotic agents.  The tools are available in the corresponding section of the STABLE Resource Toolkit.

• Metabolic Monitoring Flow Sheet:  Brief documentation tool for office-based practice

References:

1. Taylor V, MacQueen G, Association Between Bipolar Disorder and Metabolic Syndrome: A Review; J Clin Psychiatry 67:7, July 2006, 1034-1041
2. Haupt D, Newcomer J, Hyperglycemia and antipsychotic medications, J Clin Psychiatry 2001; 62 (suppl 27): 15-26
3. Cohn T, Sernyak M, Metabolic Monitoring for Patients Treated with Antipsychotic Medications, Can J Psychiatry, Vol 51, No 8, July 2006, 492-501