From the Guidelines
Before starting atypical antipsychotics, baseline laboratory tests including fasting blood glucose, hemoglobin A1c, lipid panel, complete blood count (CBC), comprehensive metabolic panel (including liver function tests), and prolactin levels should be obtained, as recommended by the most recent guidelines 1. These tests are essential to monitor the metabolic side effects associated with atypical antipsychotics, such as weight gain, hyperglycemia, diabetes, and dyslipidemia. Additionally, an electrocardiogram (ECG) should be performed to assess QTc interval, especially for medications like ziprasidone and iloperidone that carry higher risks of QT prolongation 1. Weight, body mass index (BMI), waist circumference, and blood pressure should also be measured and documented. Some agents like clozapine require additional monitoring, including absolute neutrophil count (ANC) before initiation and regularly thereafter due to the risk of agranulocytosis. For patients with risk factors for diabetes or cardiovascular disease, more comprehensive evaluation may be warranted, as suggested by the American Dietetic Association's recommendations for managing weight gain for patients taking antipsychotics 1. After initiating treatment, follow-up monitoring should occur at regular intervals, typically at 4,8, and 12 weeks, then quarterly or annually depending on the specific medication and patient risk factors, as recommended by the most recent guidelines 1. It is also important to advise patients and families about presenting symptoms of potential adverse effects because periodic monitoring does not ensure that abnormalities will be readily identified 1. The atypical antipsychotics as a class are associated with significant weight gain and other metabolic problems, thus baseline body mass index, waist circumference, blood pressure, fasting glucose, and a fasting lipid panel should be followed as recommended by the American Psychiatric Association 1. People treated with these agents should be screened for prediabetes or diabetes at baseline, rescreened 12–16 weeks after medication initiation, and screened annually thereafter, as recommended by the most recent guidelines 1.
From the FDA Drug Label
Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control.
The labs that should be run before starting atypical antipsychotics include:
- Fasting blood glucose testing for patients with risk factors for diabetes mellitus or an established diagnosis of diabetes mellitus 2 3 It is also important to monitor for symptoms of hyperglycemia, including polydipsia, polyuria, polyphagia, and weakness.
From the Research
Laboratory Tests Before Starting Atypical Antipsychotics
- Baseline liver enzyme tests are recommended before starting atypical antipsychotic therapy, including:
- Alanine aminotransferase (ALT)
- Aspartate aminotransferase (AST)
- Gamma-glutamyl transferase (GGT)
- Alkaline phosphotase (ALP)
- Serum bilirubin levels 4
- These tests are suggested to be monitored regularly, especially in patients with risk factors for liver damage during therapy 4
Rationale for Laboratory Tests
- Atypical antipsychotic drugs can cause asymptomatic increases in liver enzymes and serum bilirubin levels, although significant liver enzyme elevations are rare 4
- Certain atypical antipsychotics, such as olanzapine, may require monitoring of plasma levels to optimize response and minimize side effects 5
Additional Considerations
- Therapeutic drug monitoring is not strictly necessary for all atypical antipsychotic drugs, except for clozapine, which has an established therapeutic range 5
- Management strategies can mitigate adverse effects associated with atypical antipsychotic use, including metabolic syndrome, extrapyramidal symptoms, and tardive dyskinesia 6