1. www.uchc.edu METABOLIC SYNDROME IN A CORRECTIONS POPULATION TREATED WITH ANTIPSYCHOTICS Andrew M. Cislo, PhD Megan J. Ehret, PharmD, MS, BCPP Robert L. Trestman, MD, PhD Kirsten Shea, MBA

2. Background Metabolic Syndrome: “…a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes” obesity, glucose intolerance, dyslipidemia, hypertension 3 or more risk factors for diagnosis A.D.A.M. Medical Encyclopedia

3. Background Risk FactorDefining Level Abdominal obesity Men>102 cm Women>88 cm Triglycerides>=150 mg/dL HDL cholesterol Men<40 mg/dL Women<50 mg/dL Blood Pressure>=135/>85 mm Hg Fasting Glucose>=100 mg/dL Table adapted from Grundy et al 2004; NCEP/ATP III Guidelines

4. Background Community Prevalence of Metabolic Syndrome: 24-34% Physical Activity Poor Nutrition Substance Abuse Smoking Culture/Diet Older age Gender * Race/ethnicity Overweight Ford 2002; ADA 2004; Holt 2004; Petty 2003; Ervin 2009

5. Background Are these risk factors similarly distributed in community and prison populations? No! Younger, great majority male, over-representation of minorities, adequate nutrition, very limited substance use, no smoking Also – Over-representing SMI

6. Background Rates of MS significantly higher among SMI ~41% Second generation, or atypical, antipsychotics associated with increased MS risk McEvoy et al 2005

7. Background Clozapine Olanzapine Quetiapine Risperidone Paliperidone Aripiprazole Lurasidone Iloperidone Ziprasidone Asenapine Stahl SM 2009; De Hert M 2009; Nussbaum 2008; Scott LH 2009; Meltzer HY 2009; Weber J 2009

8. Background Correctional Managed Health Care (CMHC) at UConn Health Center Responsibility for all global medical, mental health, pharmacy, and dental service provision in integrated jail and prison system. 2 phase project Administrative data alone (described below) Medical chart review to enable use of NCEP/ATP III Guidelines

9. Background Two Major Contributions First study of MS prevalence by antipsychotics with incarcerated population Individual variation (with environmental controls) Method: Compare MS measurement criteria Traditional Modified (for use with existing electronic data)

10. Background UConn IRB approval Awaiting CT DOC determination

11. Research Questions  Are atypical antipsychotics generally associated with elevated risk for MS in corrections?  Does Rx risk for MS align with relative risk in community studies?

12. Method  CMHC e-pharmacy records July 2010- June 2012  Inclusion Criteria  Qualifying 1 st or 2 nd generation antipsychotic Rx fill during window  Received med. for at least 6 months  If fills in both gens (not concurrently):  First med. if >=6 months & 1 fill in window

13. Method  Exclusion Criterion  No med in other generation concurrently

14. Method Analytic Categories First Gen OnlySecond Gen Only First to Second GenSecond to First Gen

15. Method  Dependent Variable  Metabolic Syndrome  >=3 of the following  BMI>=25  Rx lipid modifying agent  Rx antihypertensive medication  Rx diabetic medication (Einhorn D. 2003, Lambert BL 2005, Lambert BL 2005)

16. Method Other Covariates Race/ethnicity Gender Age Time since admission Anovas and Logistic Regressions

17. Sample Description (N=X) % Race/Ethnicity White Black Hispanic % Age Group <40 years 40+ years % Sex Male Female

18. Sample Description (N=X) % Rx Generation First Gen Only Second Gen Only First to Second Second to First % Ever 2 nd Gen Ever Second % Outcome Metabolic Syndrome

19. Limitations Time ordering Sequencing of Rx history Window and sample size Administrative data Lack of randomization

20. Future Directions Medical chart reviews required Height/weight (more complete) Lab values: glucose, cholesterol panels Sequencing of antipsychotic Rx Inclusion of additional medications Mood stabilizers- lithium, valproic acid Antidepressants Stratify by psychiatric Dx

21. Future Directions  Replication  Do other states have comparable electronic data for comparison?

22. www.uchc.edu Contact Information Andrew M. Cislo, PhD Director of Research and Evaluation Correctional Managed Health Care University of Connecticut Health Center 263 Farmington Avenue, ASB Bldg., 3rd floor Farmington, CT 06030-5386 Phone: 860-282-8575 Email: cislo@uchc.edu