Laboratory Monitoring

When Prescribing
Psychotropics
When you are planning to start a patient on medications, what labs should you
order at baseline, and what should you order over time? This is quite a
different question from whether to do a set of labs at the start of treatment to
screen for disease etiology, and its an area where I believe we should be
much more proactive.

Note: Before you start any medication on a woman of child-bearing age, you
should order a urine pregnancy test just in case!

Antidepressants

Specific Serotonin Reuptake Inhibitors (SSRIs). No lab monitoring

required. However, you may want to order the appropriate labs if patients
experience any of these three recently reported medical complications of
SSRIs.

1. Bleeding. Most commonly manifesting as GI bleeding (Meijer W. Arch

Internal Medicine 2004;164:2367-2370), the bleeding risk of SSRIs is not
thought to be caused by platelet dysfunction, but is probably a direct effect of
serotonergic stimulation. This is such a rare side effect that routine monitoring
of the hematocrit is not indicated, but order a CBC if a patient presents with
symptoms suggestive of blood loss.

2. Hyponatremia. Significant SSRI-induced hyponatremia (below 130) is rare,

and it is most likely to occur in patients over 65 within 30 days of starting the
SSRI (Consult Pharm 2000;15:160-77.
http://www.ascp.com/publications/tcp/20 00/feb/cr-hypo.shtml). Again, it is too
rare a side effect to merit routine Na monitoring, but consider ordering an
electrolyte panel if an elderly patient recently started on SSRIs reports fatigue,
dizziness, or cramping.

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3. Osteoporosis. Two recent studies suggest that SSRI use decreases bone

density in the elderly, placing them at greater risk for osteoporosis. The effect
was not huge, but was large enough for the authors to recommend that elderly
patients on SSRIs should have routine bone density screenings (see this
months Research Updates for more details and references).

Effexor XR (venlafaxine XR). Patients should have their blood pressure

checked periodically after starting or increasing the dose of Effexor XR. The
risk of hypretension is dose-dependent, so monitoring should be more vigilant
at doses of 225 mg or higher.

Cymbalta (duloxetine). Since Cymbalta causes elevation of alanine

transaminase (ALT) in 1% of patients, check ALT at some point after the
patient starts it.

Tricyclics. In patients with pre-existing cardiac disease, order an ECG both

before starting a tricyclic and after reaching a therapeutic dose. Some
authorities recommend a screening ECG in any patient above 40 or 50,
regardless of cardiac history. There is some evidence endorsing the value of
monitoring the serum level of nortriptyline, with a therapeutic window of 50-
150 ng/mL correlating with the best antidepressant results.

MAOIs. Phenelzine (Nardil) has been reported to cause liver failure in case

reports (Gomez-Gil et al., Annals Internal Medicine 1996;124:692-693), so
some clinicians recommend monitoring LFTs after starting it.
Antipsychotics

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The importance of the metabolic syndrome has been pounded into our brains

as a result of the marketing wars between the different makers of atypical
antipsychotics. To review: Metabolic syndrome it is defined as a combination
of abdominal obesity, elevated fasting plasma glucose levels, elevated
triglyceride levels, low HDL cholesterol levels, and hypertension.

Several antipsychotics appear to cause the metabolic syndrome, though there

is disagreement about which ones lead to significant risk. TCPR has had the
displeasure of reviewing this very complicated literature in past issues, and
based on this we divide up the commonly used antipsychotics into two
categories: metabolically dirty vs. metabolically clean. Another good source of
recommendations came from the Mt. Sinai group (Marder et al., Am J
Psych 2004; 161:1334-1349).

Metabolically dirty antipsychotics include: Zyprexa (olanzapine), clozapine,

Risperdal (risperidone), Seroquel (quetiapine), chlorpromazine, and
thioridazine.

Metabolically clean (or at least cleaner) antipsychotics: Abilify (aripiprazole),

Geodon (ziprasidone), haloperidol, Trilafon (perphenazine).

Here are our monitoring recommendations for these two different categories:
Dirty antipsychotics. Weight. Determine BMI (body mass index, defined as
weight divided by height) at baseline, once a month for the first three months,
then every three months. Glucose. 1. Baseline fasting glucose (below 100 is
normal, 100-125 is pre-diabetes, above 126 is diabetes). If your patient can’t
manage to get to the lab before eating, order an HbA1c, which is a measure
of long term glucose control. 2. Follow-up fasting glucose 4 months after
starting med and then yearly, unless patients are gaining weight: if so,
continue Q 4 mo. monitoring. Ask patients about polyuria or polydipsia to
monitor for diabetes. Lipids. Baseline fasting lipid panel: total cholesterol,
low-density lipoprotein (LDL) and HDL cholesterol, and triglyceride levels.
Check lipids again 3 months later, then every 2 years; refer to PCP if LDL is
higher than 130 mg/dl.

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Clean antipsychotics. Weight. Baseline, 6 months, then

yearly. Glucose. Baseline glucose (fasting not necessary); then
yearly. Lipids. Baseline fasting lipid panel every 2 years.

ECG Monitoring

Mellaril (thioridazine), Serentil (mesoridazine, no longer available in U.S.), and

Orap (pimozide) should not be prescribed for anyone with known heart
disease. Geodon can be prescribed in patients with heart disease, but you
should get a baseline ECG, and get follow-up ECG. In patients with no cardiac
history, no screening ECG is required.
Prolactin

Patients on Risperdal and most first generation antipsychotics should be

asked screening questions about symptoms of elevated prolactin. For women,
ask about changes in menstruation or libido, and whether they have noticed a
milk discharge from breasts. For men, ask about libido and sexual
dysfunction. Order prolactin levels only if screening questions indicate
possible hyperprolactinemia.

Mood Stabilizers

See the Chart for recommendations on monitoring mood stabilizers.