Given the fact that patients with schizophrenia typically possess multiple cardiovascular risk factors, a full lipid panel with fractionation of cholesterol should be performed annually as part of routine health monitoring for inpatients and outpatients. With higher-risk agents for hyperlipidemia (clozapine, olanzapine, quetiapine), quarterly fasting triglycerides and TC can be considered for ongoing screening instead of the more expensive lipid panel during the first year of atypical antipsychotic therapy. This monitoring frequency for higher-risk agents is necessary to detect severe hypertriglyceridemia, which presents a risk for acute pancreatitis at triglyceride levels much greater than 500 mg/dL, and particularly at those above 1,000 mg/dL. After 1 year the monitoring frequency for patients on dibenzodiazepine-derived compounds may be decreased to annual assessment depending on the results. Although it is sometimes difficult to obtain reliable fasting specimens on outpatients, both TC and HDL are valid on nonfasting specimens.
On the basis of the laboratory and clinical data, one should calculate 10-year cardiovascular risk estimates and determine the need to refer patients for pharmacotherapy, including those with modest lipid abnormalities. (The National Heart, Lung and Blood Institute [NHLBI] has posted a useful summary of the recent NCEP guidelines for Palm operating system-based PDAs on its Web site: hin.nhlbi.nih.gov/atpiii/atp3palm.htm.) Diet and lifestyle modification are considered the mainstays of cardiovascular risk reduction, and counseling in these areas should always be offered;
however, when dietary measures have failed to normalize serum lipids, results from the landmark statin trials should make it abundantly clear that simple pharmacological interventions in those with low HDL, high LDL, or elevated triglycerides or TC may yield substantial reductions in cardiovascular morbidity and mortality. Nonetheless, undertreatment of hyper-lipidemia is an ongoing problem for many patients, even those without major mental illness who have established CHD (Smith 2000). Although mental health practitioners may not choose to institute lipid agents themselves, patients with established CHD or CHD-equivalent disorders (e.g., DM, severe atherosclerotic vascular disease) should be started on low-dose aspirin therapy (81 mg/day, or one baby aspirin); this simple intervention has been proven to reduce important vascular events by 25%-33% (Braunstein et al. 2001). On the other hand, some psychiatrists may feel comfortable initiating treatment of hyperlipidemia under the guidance of an internist, cardiologist, or family practitioner because the typical first-line medications employed, statins and fibrates (e.g., fenofibrate, gemfibrozil), are relatively safe when used individually, although there is a necessity for occasional monitoring of liver function tests and creatine kinase.
In all instances, patients with schizophrenia and persistent hyperlipi-demia must receive lipid-lowering therapy geared toward lipid goals defined by level of cardiovascular risk to minimize the likelihood of CHD and death from coronary disease. As mental health practitioners, it is important not to lose sight of the significant impact that nonpsychiatric medical comorbidity has on the chronically mentally ill. The dramatic reductions in coronary morbidity and mortality from hyperlipidemia treatment is one of the most powerful interventions available in medicine today, and this treatment should be widely available to patients with schizophrenia, who represent a group at high risk for cardiovascular disease.
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