What are the antipsychotics with less weight gain risk?

Question

Hello doctor,

My 28-year-old daughter was diagnosed with schizophrenia three years ago, after she gave birth to her son and experienced severe postpartum psychosis. She has been taking risperidone 4 mg twice daily, which controls the hallucinations, but she has gained 60 pounds since starting it and now weighs 215 pounds. Her prolactin levels are extremely high at 89 ng/mL, and she has not had a menstrual period for the past 18 months. Her psychiatrist said the elevated prolactin is caused by the antipsychotic medication.

She also developed gestational diabetes during pregnancy, and now her fasting glucose is 118, which is borderline high. We tried switching her to aripiprazole, but she developed terrible insomnia and the hallucinations returned within two weeks, so she had to go back on risperidone.

She is a single mother, and I am helping her raise my grandson, but I am worried about her long-term health. The weight gain has made her depressed, and she no longer wants to leave the house. Her bone density scan showed osteopenia, which the doctor said might be due to high prolactin levels and lack of menstrual periods.

Is there any medication for schizophrenia that does not cause as much weight gain or hormonal problems? I really need her to stay stable for her son.

Please help.

Thank you.

Answer 1

Hello,

Welcome back to icliniq.com.

I understand your concern.

I can understand it must have been difficult for you to see your daughter suffering from a mental disorder, and it does show that you care for her and your grandson.

You are absolutely right about the side effects that Risperidone causes: weight gain, high prolactin, period fluctuations, and changes in bone density. As side effects seem to be intolerable, there should be a switch. There are multiple medications other than Aripiprazole that are weight-neutral and do not change the hormonal profile.

These include Brexpiprazole, Lurasidone, and Ziprasidone. Lurasidone can cause restlessness, and Ziprasidone can cause QT interval prolongation. Practically, I have seen that Brexpiprazole is not very effective and is a similar class to Aripiprazole.

Therefore, I will recommend changing Risperidone to Ziprasidone after an ECG(electrocardiogram) review. Lifestyle modifications such as exercise, reducing sugar and total calorie intake, and taking the help of a nutritionist can help her maintain weight.

You can also initiate CBT(cognitive behavioral therapy) in psychosis for long-term management. Other therapies that are effective and should be considered are family therapy, social skills training, and cognitive remediation therapy. This therapy will reduce the burden of medicines, thus she would not need to rely only on risperidone.

This switching should be done very carefully and gradually. Small dose decrease and small dose increment of Ziprasidone, and monitor her symptoms carefully.

Another option is maintenance ECT, which is not only effective but free of side effects such as weight gain and hormonal imbalance. But cognitive side effects need special attention.

Other medicines, such as Metformin, can be added to control weight gain if all other measures fail. As she is experiencing osteopenia, add calcium and vitamin D, and she should resume weight-bearing exercises if she can tolerate them.

I hope this helps.

Please follow up if you have any further concerns.

Thank you.

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