Antipsychotic Therapy-Induced New Onset Diabetic Ketoacidosis

Abstract

Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.

Diabetic ketoacidosis and olanzapine: Case report and literature review

“…The initial phase of drug administration is usually associated with acute dysregulation of glycemic metabolism, being the leading cause of DKA. Although more common, this effect is not limited to the initiation of treatment, but death reports even 60 months after initiation of therapy [4][5][6][7]13]. The initial clinical presentation, in this case, differs from what is usual in the pathophysiology of type 1 and 2 DM.…”

“…However, it is not yet clear whether the increased incidence of diabetes mellitus is due to the use of antipsychotic medications, the presence of underlying disease, schizophrenia, or other factors such as physical inactivity, autoimmune disease, obesity, high cardiovascular risk and poor access to services of health [1,8]. The risk associated with atypical APs is higher for clozapine (2.03%), followed by quetiapine (0.80%), olanzapine (0.63%), and risperidone (0.05%) [5][6][7]9]. Besides, medications such as first-line AP, mood stabilizers (sodium valproate or lithium), clonazepam, antidepressants, antihypertensives, benzodiazepines, statins, sympathomimetics, parasympathomimetics, anticholinergics, corticosteroids, and antidiuretics are associated.…”

“…Although the association between the use of AP and the development of metabolic disorders is proven, the pathophysiological mechanisms triggering the process are not known, and the report of these events is relatively new. The first reported case of olanzapine induced DKA occurred in 1993, leading to an absolute contraindication to its use in patients with diabetes in some countries of the world [5,12]. The initial phase of drug administration is usually associated with acute dysregulation of glycemic metabolism, being the leading cause of DKA.…”

“…In contrast, most patients have considerable weight gain and insulin resistance, clinical suggestive of type 2 DM. Some patients may also have leukocytosis, related to concomitant pancreatitis or urinary tract infection [3][4][5][6]14]. Risk factors for the development of diabetes in atypical antipsychotic users are previous DM, black race, male gender, obesity, and family history in first-degree relatives with diabetes.…”

“…It is considered to be the first-line drug to treat the acute phase of the disease. However, the risk of hyperglycemic complications and other side effects such as sedation, increased appetite, dry mouth, weakness, hypercholesterolemia, hypertriglyceridemia, impaired liver function, hyperprolactinemia, and neutropenia, require appropriate follow-up of these patients, especially in the first months of treatment [5]. Despite the apparent relationship between antipsychotic use and the development of metabolic dysfunction, the prevalence or risk of the onset (incidence) of diabetes mellitus in patients treated with these drugs requires an updated approach [3].…”