A 28-year-old woman is evaluated for the recent onset of paranoid thinking. For the past 4 months, she has thought that coworkers have been spying on her and talking behind her back. She is afraid to go to work and worries that she might lose her job. She has no hallucinations or depression and no significant medical history. Her father has coronary artery disease and hypertension, and her mother has a history of depression and hypothyroidism. The patient has a 9-pack-year smoking history and drinks alcohol socially. Physical examination is unremarkable. ECG, complete blood count, comprehensive metabolic panel, and urine toxicology screen are normal. The patient is started on olanzapine. Which of the following tests would be most important to obtain at the patient's 3-month follow-up visit?

Question

A 28-year-old woman is evaluated for the recent onset of paranoid thinking.  For the past 4 months, she has thought that coworkers have been spying on her and talking behind her back.  She is afraid to go to work and worries that she might lose her job.  She has no hallucinations or depression and no significant medical history.  Her father has coronary artery disease and hypertension, and her mother has a history of depression and hypothyroidism.  The patient has a 9-pack-year smoking history and drinks alcohol socially.  Physical examination is unremarkable.  ECG, complete blood count, comprehensive metabolic panel, and urine toxicology screen are normal.  The patient is started on olanzapine.  Which of the following tests would be most important to obtain at the patient's 3-month follow-up visit?

Quizplus · Accepted Answer

11ec25c8_d796_bd9a_bc81_33459cebf172_MD0003_00 Olanzapine is a second-generation antipsychotic medication used to treat schizophrenia, bipolar disorder, and other psychotic disorders. Although second-generation antipsychotics have a lower risk of extrapyramidal side effects, they are all associated with metabolic adverse effects (eg, weight gain, dyslipidemia, hyperglycemia, increased risk of diabetes) to varying degrees. Olanzapine and clozapine appear to pose the greatest risk. Due to these potential side effects, body mass index should be measured monthly, and fasting plasma glucose and lipids, blood pressure, and waist circumference should be assessed at baseline, 3 months, and then annually. Earlier and more frequent monitoring is recommended for patients with diabetes or those who have gained >5% of initial weight. (Choices A and G) Kidney and thyroid function tests should be monitored in patients taking lithium, not olanzapine. Lithium is associated with nephrogenic diabetes insipidus, chronic interstitial nephritis, and hypothyroidism. Lithium also accumulates in patients with renal insufficiency, and dose adjustment is needed. (Choice B) Reports of olanzapine causing neutropenia or agranulocytosis are rare, and complete blood counts are not routinely checked. The risk for agranulocytosis is higher with clozapine, which requires weekly blood counts during the first 6 months of treatment. (Choice C) ECG is not routinely required in patients on olanzapine. However, ECG monitoring is advised for those with a history of cardiac disease. The second-generation antipsychotic ziprasidone has been associated with QT prolongation at higher doses. (Choice E) Antipsychotic drugs can cause asymptomatic increases in liver enzymes, but significant liver enzyme elevations are rare. In asymptomatic patients, it is reasonable to obtain liver function tests at baseline and then yearly. (Choice F) Hyperprolactinemia (galactorrhea, menstrual disturbances, sexual dysfunction, gynecomastia) can occur with first-generation antipsychotics and the second-generation antipsychotic risperidone. Olanzapine, however, does not commonly increase prolactin levels. Educational objective: Second-generation antipsychotics cause metabolic side effects (eg, weight gain, hyperglycemia, dyslipidemia) to varying degrees. Routine monitoring for the development of these side effects is recommended in patients taking second-generation antipsychotics. Olanzapine and clozapine are associated with the greatest risk. References: Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications. (http://www.ncbi.nlm.nih.gov/pubmed/19083283) Second-generation antipsychotics and metabolic side effects: a systematic review of population-based studies. (http://www.ncbi.nlm.nih.gov/pubmed/28585153)

A 28-Year-Old Woman Is Evaluated for the Recent Onset of Paranoid