What is the best course of action for a patient with Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and diabetes, who is taking Risperidone (risperidone) 0.5mg and experiencing binge eating at night, which she attributes to the medication?

Management of Risperidone-Associated Binge Eating in a Patient with GAD, MDD, and Diabetes

You should switch from risperidone to a weight-neutral antipsychotic such as lurasidone or ziprasidone, or consider aripiprazole as a lower-risk alternative, given that risperidone is consistently associated with weight gain and metabolic dysregulation, which is particularly problematic in a patient who already has diabetes and is experiencing binge eating. 1

Understanding the Problem

Risperidone's Metabolic Effects

• Risperidone is consistently associated with weight gain and metabolic changes including hyperglycemia and dyslipidemia, making it a particularly poor choice for patients with pre-existing diabetes 1, 2
• The FDA label explicitly warns that atypical antipsychotics like risperidone have been associated with metabolic changes that increase cardiovascular/cerebrovascular risk, including body weight gain 2
• Patients with established diabetes who are started on atypical antipsychotics including risperidone should be monitored regularly for worsening of glucose control 2
• Risperidone has been reported to cause diabetic ketoacidosis in some cases, demonstrating its potential to severely worsen glycemic control 3

The Binge Eating Connection

• Binge eating in type 2 diabetes is commonly reported and involves excessive food intake with an accompanying sense of loss of control 1
• The patient's attribution of binge eating to risperidone is likely accurate, as antipsychotics can increase appetite and food cravings through multiple mechanisms including histamine H1 receptor antagonism 1

Immediate Action Plan

Step 1: Switch Antipsychotic Medication

• Lurasidone and ziprasidone are the most weight-neutral antipsychotics in the class, making them the preferred alternatives 1
• Aripiprazole generally demonstrates a lower risk for weight gain as well and can be considered 1
• Studies demonstrate that patients may lose weight and develop improved glucose tolerance when switched from weight-gaining antipsychotics like risperidone to ziprasidone 1
• The dose of 0.5mg risperidone is relatively low, which should make the transition easier with lower risk of withdrawal symptoms

Step 2: Monitor Metabolic Parameters Closely

• Patients taking second-generation antipsychotics require greater monitoring because of increased risk of type 2 diabetes 1
• The American Diabetes Association recommends that changes in weight, glycemic control, and cholesterol levels should be carefully monitored when antipsychotic medications are prescribed 1
• Obtain fasting blood glucose testing periodically during treatment with any atypical antipsychotic 2
• Monitor for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness 2

Addressing the Binge Eating Directly

Pharmacological Options for Binge Eating

• If binge eating persists after switching antipsychotics, consider adding specific treatment for binge-eating disorder 4
• Lisdexamfetamine is the only FDA-approved medication for binge-eating disorder and has the added benefit of promoting weight loss 4, 5
• Topiramate has been consistently associated with weight loss and has shown efficacy in reducing binge eating behavior and body weight in patients with binge-eating disorder 1, 6, 5
• SSRIs (fluoxetine, sertraline, fluvoxamine, citalopram) have been shown to modestly reduce binge eating frequency and body weight over the short term 6

Optimizing Antidepressant Therapy

• Review the current antidepressant regimen for GAD and MDD to ensure it is not contributing to weight gain 1
• Within SSRIs, fluoxetine and sertraline are associated with weight loss with short-term use and weight neutrality with long-term use 1
• Paroxetine and amitriptyline are associated with the greatest risk for weight gain and should be avoided 1
• Bupropion is the only antidepressant that consistently promotes weight loss through appetite suppression and reducing food cravings, though it can exacerbate anxiety 1, 7
• Mirtazapine should be avoided as it is closely associated with weight gain 1

Critical Caveats and Pitfalls

Bupropion Considerations

• While bupropion promotes weight loss and may help with binge eating, it is activating and can exacerbate anxiety, which is problematic for this patient with GAD 1
• Bupropion did not improve binge eating relative to placebo in one controlled trial, though it did produce modest weight loss 7
• The choice must be guided by the individual patient's anxiety severity 1

GLP-1 Receptor Agonists

• Adjunctive medication such as GLP-1 receptor agonists may help individuals not only meet glycemic targets but also regulate hunger and food intake, potentially reducing uncontrollable hunger and bulimic symptoms 1
• This is particularly relevant given the patient's diabetes diagnosis and could address both metabolic control and binge eating simultaneously 1

Monitoring During Transition

• Annual screening for prediabetes or diabetes is recommended for all patients prescribed atypical antipsychotic medications 1
• Incorporate monitoring of diabetes self-care activities into treatment goals 1
• The risk-benefit ratio must be continuously monitored when using antipsychotics, with particular attention to weight gain and metabolic dysregulation 1

Avoiding Common Mistakes

• Do not continue risperidone simply because the dose is low (0.5mg) - even low doses can cause metabolic problems 2
• Do not dismiss the patient's attribution of binge eating to risperidone - this is a well-documented adverse effect 1, 2
• Do not add medications to treat binge eating without first addressing the causative agent (risperidone) 1
• Do not delay the switch due to concerns about psychiatric stability - the metabolic risks in a diabetic patient outweigh the inconvenience of switching 1, 2