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Information BiochemistryDateResultNotes Creatinine75mmol/LNormal Height170cm weight107kg hbA1c8%> 7% LFT’sok Cigarettes a day High end bracket No cannabis Age24 Years BMI37>30 = obese Cholesterol7.5 mmol/L

Medicines DrugDoseNotes Olanzapine 20mg1 bdSchizophrenia mgmt 2 nd gen Risperidone 2-3mg1 bdSchizophrenia mgmt 2 nd gen Metformin 850mg1 bdDiabetes metillus Simvastatin 80mg1 nDyslipidaemia Alprazolam 1mg1 nShort acting benzo Temazepam 10mg1 n prnIntermediate benzo Valerian1 nHerbal sleeping

What was found Found double dose of benzodiazepines Double dose of atypical antipsychotics Valerian triple dosing sleeping pill Simvastatin 80mg is high dose Need more effective control of blood glucose

What literature says Doubling of the atypical antipsychotics is only acceptable in transition period of changing between 2 antipsychotics. Using 2 at once increases metabolic side effects and could worsen diabetes and dyslipidemia. Double the benzo’s could lead to respiratory depression and death especially when mixed with alcohol. Valerian is also unnecessary Simvastatin is high dose 80mg. Blood glucose levels need to be controlled more.

Sleeping Aids Recommend stay on temazepam at night and remain at prn for 4 weeks only at a time to avoid addiction Taper off alprazolam and stop it TGs: “There is little basis for the use of >1 benzodiazepine concurrently in any patient” Recommend removal of valerian

Simvastatin Patient is taking simvastatin 80mg a day Total cholesterol levels = 7.5mmol/L  high – Recommended is <5.5mmol/L (AMH) or <4mmol/L (TGs) Consider changing to Atorvastatin 20mg – Found to be the most effective in increasing HDL in study by Asztalos et al

Anti Psychotics Doubling of the atypical antipsychotics is only acceptable in transition period of changing between 2 antipsychotics. Using 2 at once increases metabolic side effects and could worsen diabetes and dyslipidemia. AMH: “ avoid use of >1 anitpsychotic, except in periods of cross-over from one drug to another” TG: “all antipsychotic drugs should be used as monotherapy” Stay on olanzapine and taper off risperidone

Metformin Random fasting blood glucose was significantly elevated HbA1c = 8% - should be roughly 7% TG recommends addition of second agent. Although, due to high BMI, need a weight neutral agent. Consider increasing exercise and making lifestyle changes Recommendation = sitagliptin 50mg + metformin 850mg (Janumet 50/850mg) – Sitagliptin weight neutral therefore more ideal than sulphonylureas which cause weight gain