What psych meds (psychiatric medications) can cause hypertriglyceridemia?

Psychiatric Medications That Can Cause Hypertriglyceridemia

Atypical antipsychotics are the primary psychiatric medications that can cause hypertriglyceridemia, with clozapine and olanzapine having the highest risk, followed by quetiapine and risperidone, while aripiprazole and ziprasidone have lower risk. 1

Atypical Antipsychotics and Hypertriglyceridemia

High Risk

• Clozapine: Associated with significant increases in triglyceride levels, with clinically meaningful elevations in over one-third of patients 2
• Olanzapine: FDA labeling specifically warns about "clinically significant, and sometimes very high (>500 mg/dL), elevations in triglyceride levels" with olanzapine use 3
• Quetiapine: Associated with higher risk of hyperlipidemia compared to other atypical antipsychotics 4

Moderate Risk

• Risperidone: Can cause hypertriglyceridemia, though at lower rates than clozapine and olanzapine 5, 4

Lower Risk

• Aripiprazole: Associated with fewer metabolic effects and lower risk of hyperlipidemia 1, 4
• Ziprasidone: Considered to have minimal effects on lipid metabolism compared to other atypical antipsychotics 1, 4

Mechanism and Timing

• Hypertriglyceridemia can develop rapidly after initiation of atypical antipsychotics, sometimes within the first 2 weeks of treatment 5
• Triglyceride elevations can occur even without significant weight gain, suggesting direct metabolic effects 5, 6
• Postprandial triglyceride levels may be affected before fasting levels show changes 6

Risk Factors for Antipsychotic-Induced Hypertriglyceridemia

• Pre-existing metabolic syndrome 5
• Obesity 5
• Concurrent alcohol use 7
• Longer duration of treatment 2

Severity and Complications

• Severe hypertriglyceridemia (>500 mg/dL) increases risk of acute pancreatitis 1
• Very severe hypertriglyceridemia (>2,000 mg/dL) significantly increases pancreatitis risk 1
• Case reports document severe complications including pancreatitis and thrombotic thrombocytopenic purpura with quetiapine-induced hypertriglyceridemia 7

Other Psychiatric Medications That May Affect Triglycerides

• Mood stabilizers:

  • Valproic acid can cause weight gain and may contribute to elevated triglycerides 1
  • Carbamazepine has been associated with weight gain that may affect lipid profiles 1
  • Lithium can cause weight gain that may indirectly affect triglyceride levels 1

• Antidepressants:

  • Most SSRIs are generally weight-neutral or may cause weight loss initially 1
  • Mirtazapine is associated with weight gain that could indirectly affect triglycerides 1

Monitoring and Management

• Baseline lipid panel should be obtained in all patients before starting antipsychotics 4
• For high-risk medications (clozapine, olanzapine, quetiapine), monitor lipids quarterly 4
• For lower-risk medications (aripiprazole, ziprasidone, risperidone), monitor lipids annually 4
• Consider medication switch to a less metabolically active agent if significant hypertriglyceridemia develops 4

Clinical Pearls

• The risk of hypertriglyceridemia with atypical antipsychotics exists on a spectrum, with clozapine and olanzapine consistently showing the highest risk 4, 2
• Hypertriglyceridemia can occur independently of weight gain, suggesting direct metabolic effects 5
• Severe cases may require discontinuation of the offending medication 7
• When possible, select antipsychotics with lower metabolic risk in patients with pre-existing dyslipidemia or metabolic syndrome 1, 4