Pediatrics – Adolescent Medicine
Guideline: Metformin to Prevent Antipsychotic-Induced Weight Gain
23 Dec, 2024 | 20:55h | UTCIntroduction:
This guideline was developed to address a pressing need for strategies to prevent antipsychotic-induced weight gain (AIWG), a frequent and troubling adverse effect of treatment in individuals with severe mental illness (SMI). Although metformin has shown consistent benefits in mitigating weight gain when initiated alongside antipsychotics, clinical uptake remains limited. The guideline follows the AGREE II framework and synthesizes both randomized and observational research, including Cochrane and meta-analytic data. The primary objective is to outline explicit indications, dosing approaches, and duration for using metformin to avert AIWG.
Key Recommendations:
- Co-initiation With High-Risk Agents: In patients requiring higher-risk antipsychotics (olanzapine, clozapine), start metformin simultaneously. Evidence suggests that concurrent treatment may lessen weight gain by 3 to 5 kg in the early months, potentially yielding greater benefits over time.
- Co-initiation With Medium-Risk Agents: For individuals prescribed quetiapine, paliperidone, or risperidone who have at least one cardiometabolic risk factor (such as diabetes, prediabetes, hypertension, or BMI above 25) or who are 10 to 25 years old, begin metformin at antipsychotic initiation to curb rapid weight changes.
- Initiation During the First Year: If, at any point in the first year of antipsychotic treatment, weight gain exceeds 3% over baseline, consider adding metformin regardless of the antipsychotic being used.
- Titration Schedule and Safety: The guideline advises starting at 500 mg once daily, then moving to 500 mg twice daily after about two weeks, with subsequent increases every two weeks up to 1 g twice daily (2 g/day) as tolerated. Metformin must be discontinued if lactic acidosis is suspected, if BMI falls below 20, or if the antipsychotic is stopped. Avoid its use in harmful alcohol consumption.
- Additional Treatment Options: In cases of obesity (BMI ≥30) or comorbid metabolic disorders, clinicians should consider adding glucagon-like peptide-1 receptor agonists (GLP-1) where available. If cost, supply, or access is limited, metformin remains a practical alternative.
Conclusion:
This is the first evidence-based guideline focused on preventing AIWG by starting metformin at the time of antipsychotic initiation or upon early weight gain signs. By reducing the magnitude of weight increase, metformin may alleviate health risks tied to obesity, as well as psychological distress and nonadherence to treatment. Implementing the guideline involves continuous weight monitoring, structured dose adjustments, and shared decision-making. Ensuring clear communication about benefits and potential side effects will be crucial for sustaining adherence and improving patient outcomes.
Reference:
Carolan A, Hynes-Ryan C, Agarwal SM, Bourke R, Cullen W, Gaughran F, Hahn MK, Krivoy A, Lally J, Leucht S, et al. Metformin for the Prevention of Antipsychotic-Induced Weight Gain: Guideline Development and Consensus Validation. Schizophrenia Bulletin. 2024; sbae205.
DOI: https://doi.org/10.1093/schbul/sbae205
Additional Commentaries:
- Psychiatric News Alert: https://alert.psychnews.org/2024/12/new-guideline-advises-metformin-to.html
- Zagorski N. Metformin May Reduce Weight Gain in Youth Taking Antipsychotics. Psychiatric News. 2024; 59(01). https://psychiatryonline.org/doi/full/10.1176/appi.pn.2024.01.1.22
Cohort Study: Levonorgestrel IUD Use Linked to Increased Breast Cancer Risk in Premenopausal Women
20 Oct, 2024 | 18:13h | UTCBackground: Levonorgestrel-releasing intrauterine systems (LNG-IUSs) are increasingly used, especially among Danish premenopausal women over 30 years old, as a preferred method of hormonal contraception. Previous studies have suggested an increased risk of breast cancer with LNG-IUS use but did not adequately address the duration of continuous use or account for other hormonal contraceptive exposures.
Objective: To assess the risk of breast cancer associated with continuous use of LNG-IUSs, accounting for other hormonal exposures.
Methods: In this nationwide Danish cohort study, 78,595 first-time LNG-IUS users aged 15–49 years from 2000 to 2019 were identified and matched 1:1 by birth year to nonusers of hormonal contraceptives. Exclusion criteria included prior hormonal contraceptive use within 5 years, previous cancer, postmenopausal hormone therapy, and pregnancy at baseline. Participants were followed from initiation until breast cancer diagnosis, other cancer, pregnancy, hormone therapy initiation, emigration, death, or December 31, 2022. Cox proportional hazards models adjusted for confounders estimated hazard ratios (HRs) for breast cancer associated with continuous LNG-IUS use.
Results: During a mean follow-up of 6.8 years, 1,617 breast cancer cases occurred: 720 among LNG-IUS users and 897 among nonusers. The mean age was 38 years. Continuous LNG-IUS use was associated with a higher breast cancer risk compared to nonuse (HR, 1.4; 95% CI, 1.2–1.5). HRs by duration were 1.3 (95% CI, 1.1–1.5) for 0–5 years, 1.4 (95% CI, 1.1–1.7) for >5–10 years, and 1.8 (95% CI, 1.2–2.6) for >10–15 years. Excess breast cancer cases per 10,000 users were 14 (95% CI, 6–23), 29 (95% CI, 9–50), and 71 (95% CI, 15–127), respectively. The trend test for duration was not statistically significant (P = .15).
Conclusions: Continuous use of LNG-IUSs was associated with an increased risk of breast cancer among women aged 15–49 years compared to nonuse of hormonal contraceptives. The absolute increase in risk was low.
Implications for Practice: Healthcare providers should inform women about the potential increased breast cancer risk associated with LNG-IUS use, especially considering its widespread and long-term use among premenopausal women. While the absolute risk increase is small, this information is essential for making informed contraceptive choices.
Study Strengths and Limitations: Strengths include the large, nationwide cohort and adjustment for multiple confounders. Limitations include potential underestimation of risk due to unrecorded LNG-IUS removals before the recommended duration, lack of a statistically significant trend with duration suggesting possible low statistical precision or non-causal association, and the possibility of unmeasured confounding.
Future Research: Further studies are needed to confirm these findings, clarify the causal relationship, and understand the mechanisms underlying the potential increased breast cancer risk with LNG-IUS use.
Cohort Study: Lower Risk of Cardiovascular Complications in Post–COVID-19 Vaccine Myocarditis Compared to Conventional Etiologies
7 Sep, 2024 | 20:36h | UTCStudy Design and Population: This French nationwide cohort study included 4,635 individuals aged 12-49 hospitalized for myocarditis between December 2020 and June 2022. The cohort was divided into three groups: 558 patients with post–COVID-19 mRNA vaccine myocarditis, 298 with post–COVID-19 infection myocarditis, and 3,779 with conventional myocarditis.
Main Findings: At 18 months of follow-up, the frequency of cardiovascular events was significantly lower in the postvaccine myocarditis group (5.7%) compared to conventional myocarditis (13.2%) with a weighted hazard ratio (wHR) of 0.55 (95% CI, 0.36-0.86). Hospital readmission for myopericarditis occurred in 3.2% of postvaccine cases, 4.0% of post–COVID-19 cases, and 5.8% of conventional cases. The all-cause mortality rate was 0.2% for postvaccine myocarditis, 1.3% for post–COVID-19 myocarditis, and 1.3% for conventional myocarditis.
Implications for Practice: Postvaccine myocarditis patients, primarily young males, experience fewer complications compared to conventional myocarditis, but long-term follow-up is still needed. These findings should guide future mRNA vaccine recommendations and clinical management for myocarditis patients.
Reference: Semenzato L. et al. (2024). Long-term Prognosis of Myocarditis Attributed to COVID-19 mRNA Vaccination, SARS-CoV-2, or Conventional Etiologies. JAMA, Online. DOI: http://doi.org/10.1001/jama.2024.16380
Link: https://jamanetwork.com/journals/jama/fullarticle/2822933
Meta-analysis reveals 24% prevalence of eating disorders among individuals with insulin-dependent diabetes – Eat Behav
11 May, 2024 | 13:41h | UTCThis systematic review and meta-analysis evaluated the prevalence of eating disorder symptoms (EDS) in individuals aged 16 and older with insulin-dependent diabetes, covering both type 1 and type 2 diabetes. The study involved an extensive search across several databases including PubMed, Embase, Scopus, PsycINFO, and CINAHL, culminating in the inclusion of 45 studies. The meta-analysis revealed a pooled prevalence of EDS at 24% (95% CI 0.21–0.28), with prevalence reaching 27% (95% CI 0.24–0.31) among studies using the Diabetes Eating Problem Survey-Revised (DEPS-R), the most frequently utilized screening tool. Notably, the prevalence of EDS varied based on the screening tool used and was significantly associated with sex distribution; studies with a higher percentage of female participants (over 58%) reported a higher prevalence of EDS (30% vs. 18%, prevalence ratio 1.7). The study also highlighted a concerning prevalence of insulin omission, reported at 21% (95% CI 0.13–0.33). This analysis underscores the substantial occurrence of eating disorder symptoms among this patient population, emphasizing the need for tailored screening and interventions.
Reference (link to abstract – $ for full-text):
M-A | Oral isotretinoin and triple topical therapies found most effective in acne vulgaris treatment
26 Jul, 2023 | 13:13h | UTC
Health advisory on social media use in adolescence
11 Jul, 2023 | 14:03h | UTCHealth advisory on social media use in adolescence – American Psychological Association
News Release: APA panel issues recommendations for adolescent social media use – American Psychological Association
Review | Diagnosis and management of depression in adolescents
13 Jun, 2023 | 14:05h | UTCDiagnosis and management of depression in adolescents – Canadian Medical Association Journal
News Release: How to diagnose and manage depression in adolescents: A new review for clinicians – Canadian Medical Association Journal
Podcast | Ascend your understanding of pelvic inflammatory disease
6 Jun, 2023 | 14:23h | UTC#83: Ascend Your Understanding of Pelvic Inflammatory Disease (PID) – The Cribsiders
Cohort Study | Cannabis use disorder linked to increased risk of depression and bipolar disorder
5 Jun, 2023 | 13:26h | UTCCannabis Use Disorder and Subsequent Risk of Psychotic and Nonpsychotic Unipolar Depression and Bipolar Disorder – JAMA Psychiatry (link to abstract – $ for full-text)
Author Interview: Cannabis Use Disorder and Subsequent Risk of Unipolar Depression and Bipolar Disorder
Commentary: Expert reaction to study of cannabis use disorder, bipolar disorder, and depression – Science Media Centre
FDA warns of use of selective androgen receptor modulators (SARMs) among teens, young adults
10 May, 2023 | 16:00h | UTCCommentaries:
FDA issues warning for bodybuilding products marketed to teens, young adults – AAP News
Young Men Are Using Banned ‘SARM’ Supplements to Bulk Up, With Harmful Results – HealthDay
Guideline | Assessment and treatment of children and adolescents with major and persistent depressive disorders
10 May, 2023 | 15:37h | UTC
Adolescent sudden cardiac death: the role of underlying conditions and physical activity
5 Apr, 2023 | 13:26h | UTCSudden Cardiac Death Among Adolescents in the United Kingdom – Journal of the American College of Cardiology (link to abstract – $ for full-text)
Commentary on Twitter
Among the causes of SCD in adolescents, arrhythmogenic #cardiomyopathy, coronary artery anomalies & commotio cordis are more common in young athletes who die suddenly than in similarly aged sedentary individuals.
Read more on this https://t.co/VHRIiNz1hE… pic.twitter.com/N3bev3Nv8i
— JACC Journals (@JACCJournals) March 14, 2023
Perspective | Teen girls are faring worse than boys on nearly all mental health measures—here’s why
3 Apr, 2023 | 13:33h | UTCTeen Girls Are Faring Worse Than Boys on Nearly All Mental Health Measures—Here’s Why – JAMA (free for a limited period)
Commentary on Twitter
The latest @CDCgov Youth Risk Behavior Survey, administered in 2021, shows that mental health has worsened for all adolescents, but especially for girls. Nearly a third of teen girls said they seriously considered suicide. https://t.co/gVHoLYtI5b #MedicalNews
— JAMA (@JAMA_current) March 28, 2023
Update on current contraceptive options | A case-based discussion of efficacy, eligibility, and use
7 Mar, 2023 | 13:06h | UTC
Report | Economic impact of overweight and obesity to surpass $4 trillion by 2035
6 Mar, 2023 | 14:32h | UTCSummary:
A recent report from the World Obesity Federation has issued a warning that the number of people worldwide suffering from overweight or obesity could increase significantly by 2035, surpassing the 50% mark. The report, called the World Obesity Atlas 2023, also highlights the significant economic impact of this trend, estimating that the cost of overweight and obesity could reach $4.32tn annually by 2035, equivalent to almost 3% of the global GDP.
The report also identifies two groups that are particularly at risk: children and individuals from lower-income countries. Childhood obesity is a growing concern, as the report predicts it could double by 2035. Additionally, lower-income countries face a rapid increase in obesity prevalence, with nine out of 10 countries with the greatest expected increases in obesity coming from low or lower-middle income countries.
Report: World Obesity Atlas 2023
News release: Economic impact of overweight and obesity to surpass $4 trillion by 2035
Commentary: Report: Obesity could cost the world over $4 trillion a year by 2035 – STAT
Related:
Report: Tenfold increase in childhood and adolescent obesity in four decades
Global cost of obesity-related illness to hit $1.2tn a year from 2025
The Lancet Series: The Double Burden of Malnutrition
RCT | Reducing social media use improves appearance and weight esteem in youth with emotional distress
3 Mar, 2023 | 14:04h | UTCSummary: The article discusses a randomized controlled trial conducted on 220 participants aged 17-25 to examine the effects of reducing smartphone social media use (SMU) on appearance and weight esteem in youth with emotional distress. The participants were divided into an intervention group (limited to 1 hr/day SMU) and a control group (unrestricted SMU). The study found that reducing SMU improved appearance and weight esteem in the intervention group, while the control group showed no significant change. The authors concluded that reducing SMU may be a feasible and effective method of improving body image in a vulnerable youth population and should be evaluated as a potential component in treating body image-related disturbances. It is worth noting, however, that the impossibility of blinding participants and the subjective nature of the endpoints make it difficult to draw definitive conclusions on the subject.
News Release: Reducing social media use significantly improves body image in teens, young adults – American Psychological Association
Commentary: How to help young people limit screen time — and feel better about how they look – NPR
M-A | Disordered eating affects 1 in 5 children and adolescents
23 Feb, 2023 | 13:33h | UTCSummary: The text reports the findings of a systematic review and meta-analysis that included 32 studies on the global proportion of disordered eating in children and adolescents aged 6 to 18 years, assessed with the SCOFF questionnaire, a widely used screening measure for eating disorders. The review found that approximately 22% of children and adolescents showed disordered eating, which was higher among girls, older adolescents, and those with higher body mass index. The high figures are concerning from a public health perspective and highlight the need for prevention strategies to address disordered eating. The study has limitations, including the cross-sectional nature of most of the included studies and the use of self-report questionnaires to assess disordered eating, which may be subject to bias.
Article: Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis – JAMA Pediatrics (free for a limited period)
Commentary: What is disordered eating? And why do 20% of the world’s kids show signs of it? Experts explain – CNN
Transition from pediatric to adult healthcare: a review on the recommendations of young adults with lived experience
9 Feb, 2023 | 13:29h | UTC
APA Guideline for the treatment of patients with eating disorders
3 Feb, 2023 | 14:26h | UTCNews Release: APA Releases Updated Guideline for Treating Eating Disorders – American Psychiatric Association
AAP Policy Statement | The hospitalized adolescent
3 Feb, 2023 | 14:09h | UTCPolicy Statement: The Hospitalized Adolescent – Pediatrics
Clinical Report: The Hospitalized Adolescent – Pediatrics
News Release: American Academy of Pediatrics Issues New Recommendations on Hospitalized Adolescents – American Academy of Pediatrics
WHO Pocket book of primary health care for children and adolescents.
1 Dec, 2022 | 14:09h | UTC
WHO updates recommendations to guide family planning decisions.
24 Nov, 2022 | 13:38h | UTCNews Release: WHO updates recommendations to guide family planning decisions – World Health Organization
Family planning: A global handbook for providers – World Health Organization (PDF)
Commentary on Twitter (thread – click for more)
👉WHO releases important updates to its Family Planning Handbook 🔖
⏭providing health workers and policymakers with the most updated information on contraceptive options.
Know more:🔗https://t.co/UhC1BFca2r pic.twitter.com/LQEtm3wmbZ
— World Health Organization (WHO) (@WHO) November 15, 2022
RCT | Once-weekly Semaglutide effective for weight loss in adolescents with obesity.
4 Nov, 2022 | 13:59h | UTCOnce-Weekly Semaglutide in Adolescents with Obesity – New England Journal of Medicine (link to abstract – $ for full-text)
Commentaries:
STEP TEENS: High-dose semaglutide weight loss benefits shown in adolescents – medwire News
Trial Shows Weight-Loss Drug Works in Teens – HealthDay
Commentary on Twitter
In this trial, adolescents with obesity assigned to weekly subcutaneous semaglutide plus lifestyle intervention had a greater reduction in BMI than those who received lifestyle intervention alone. https://t.co/yiFseP38xa pic.twitter.com/uRqkFfon1s
— NEJM (@NEJM) November 2, 2022
Cross-Sectional Study | Prevalence of and factors associated with high blood pressure among adolescents in India.
3 Nov, 2022 | 13:57h | UTCInvited Commentary: Prevalence of High Blood Pressure Among Youth in India and Association With Future Cardiovascular Disease – JAMA Network Open
Commentary on Twitter
1 in 3 adolescents in India have high BP, which is is associated with the trifecta of overweight/obesity, high blood sugar, high blood lipids, and can be prevented. #OAResearch https://t.co/i2Cth5ol2T
— JAMA Network Open (@JAMANetworkOpen) October 31, 2022
RCT | Impact of vaping prevention advertisements on adolescents.
14 Oct, 2022 | 13:57h | UTCNews Release: Researchers find FDA ‘Real Cost’ ads reduce teen openness to vaping – UNC Lineberger Comprehensive Cancer Center
Commentary on Twitter
RCT: Real Cost vaping prevention ads led to lower youth susceptibility to vaping and discouraged cigarette smoking. #OAReaserch https://t.co/ASl5oXbn5Z pic.twitter.com/9Uaj4zc7sK
— JAMA Network Open (@JAMANetworkOpen) October 13, 2022