Endo Sdm Antipsychotic

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name: endo-sdm-antipsychotic
description: Recommends using weight‑neutral antipsychotic alternatives when possible and employing shared decision‑making that provides quantitative estimates of expected weight effect to guide drug choice. Triggered when a clinician asks, “How do I involve this patient in choosing an antipsychotic with minimal weight gain?” or “What resources show weight‑change projections for risperidone vs aripiprazole?”.
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# Shared decision‑making for antipsychotics with weight‑effect estimates

## STEP 1 — Gather Information
Collect psychiatric indication, current weight and BMI, prior weight changes with psychotropics, patient’s weight‑related concerns and preferences, baseline metabolic labs (glucose, lipids), and any contraindications to specific agents.

## STEP 2 — Rule In / Rule Out
Is an antipsychotic clinically indicated for the patient’s condition?  
- **No:** Consider non‑pharmacologic therapies or alternative medication classes; revisit if symptoms persist.  
- **Yes:** Proceed to classify available antipsychotic options by weight effect.

## STEP 3 — Classify or Stratify
Stratify candidate antipsychotics into weight‑neutral (e.g., aripiprazole, ziprasidone, lurasidone) and weight‑gain (e.g., olanzapine, clozapine, quetiapine, risperidone) groups using published mean weight‑change data over 12 weeks:  
- Aripiprazole ≈ +0.5 kg, Ziprasidone ≈ 0 kg, Lurasidone ≈ +0.2 kg  
- Risperidone ≈ +2 kg, Quetiapine ≈ +2.5 kg, Olanzapine ≈ +4.5 kg, Clozapine ≈ +3.5 kg  
Create a shortlist that matches efficacy needs with the lowest expected weight impact.

## STEP 4 — Decide
Engage in shared decision‑making using a decision aid that presents the quantitative weight‑change estimates alongside efficacy, side‑effect profile, and cost; select the agent that best balances therapeutic goals and weight concerns; document the discussion, the patient’s values, and the agreed‑upon prescription.

## Clinical Guardrails / Mimics / Pitfalls
Do not default to high‑risk weight‑gain agents (olanzapine, clozapine) in patients with obesity or metabolic syndrome without explicit discussion of weight impact; avoid ignoring the patient’s weight‑related values; do not rely solely on efficacy data when choosing antipsychotics; monitor weight at baseline and regularly (e.g., monthly for the first 3 months, then quarterly) to detect early changes.

## Concrete Clinical Example
A 32‑year‑old man with schizophrenia, BMI 29 kg/m², reports worsening psychosis and worries about weight gain. The clinician discusses options: aripiprazole (expected weight change +0.5 kg over 12 weeks) versus olanzapine (+4.5 kg). The patient chooses aripiprazole; treatment starts at 5 mg daily with a weight check scheduled in 4 weeks.

**Source:** Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2015, DOI:10.1210/jc.2014-3415