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Risperidone alternative for a schizophrenic patient with olanzapine‐exacerbated diabetic mellitus

Olanzapine and clozapine are chemically distinct from risperidone. 1 The former ones are reported to be associated the most with weight gain, new-onset type 2 diabetes mellitus (DM) and hyperlipidemia, 2,3 compared to risperidone. 3,4 We here report a schizophrenic patient with oral hypoglycemic agent (OHA)-refractory type-2 DM, whose blood glucose level returned to normal after beginning treatment with risperidone as the alternative to olanzapine. Mr A, a 42-year-old male, had been diagnosed with paranoid schizophrenia for 12 years and had a family history of type 2 DM. He was treated with sulpiride at the dosage of 400 mg/day for his psychotic symptoms for more than 3 years. He was found to have hyperlipidemia with triglyceride 1080 mg/dL and total cholesterol 340 mg/dL, and hyperglycemia with the fasting blood glucose levels around 190 mg/dL. Only gemfibrozil 600 mg/day had been given 3 years ago and the condition was controlled. Because of prominent negative symptoms and functional deterioration, he was then switched to olanzapine at 10 mg/day and his mental status improved gradually. However, with the regular treatment of glimperide 4 mg/day, metformin 2000 mg/day, and gemfibrozil 1200 mg/day, his hyperlipidemia and hyperglycemia exacerbated and remained poorly controlled. His fasting blood glucose levels were abnormal, ranging from 171 to 246 mg/dL and the glycohemoglobin levels were around 12% with the treatment of olanzapine for the past 2 years. We therefore decided to discontinue olanzapine therapy and start with risperidone 2 mg/day instead due to the metabolic dysregulation refractory to the regular OHA treatment. The day after olanzapine was withdrawn, Mr A experienced hypoglycemic-like symptoms, such as dizziness, cold sweating and palpitation. His metformin dose was then tapered by 50%, and his fasting blood glucose levels dropped to 110 mg/dL and remained stable for the five consecutive measurements, ranging from 97 to 113 mg/dL. Moreover, the glycohemoglobin value decreased to 6% in 6 weeks after starting on risperidone. Another significant finding was that his lipid profiles also improved, 227 mg/dL in triglyceride and 203 mg/dL in total cholesterol, even with a 50% tapered dose of lipid-lowering agents. Mr A’s psychotic symptoms remained stable for the following 5-month follow up with risperidone therapy. There were many case reports of new-onset or exacerbated diabetes associated with olanzapine treatment; 5,6 Although the majority of the patients still required insulin therapy or oral hyperglycemic medication after discontinuing olanzapine, 7 some cases found that the hyperglycemia resolved and no further treatment was needed. 2,7