Two Cases of Diabetic Ketoacidosis Associated with Paliperidone Treatment in Schizophrenia

Hyun Ho Kim; Hae Kyung Yang; Hyoju Ham; Ho Wook Jeon; Joon Yub Lee; Sea Won Hwang; Bo Hyun Jang; Gi June Min; Jeong Min Lee; Seung-Hwan Lee

doi:10.4093/jkd.2014.15.3.178

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Kim, Yang, Ham, Jeon, Lee, Hwang, Jang, Min, Lee, and Lee: Two Cases of Diabetic Ketoacidosis Associated with Paliperidone Treatment in Schizophrenia

Original Articles & Case Reports

J Korean Diabetes 2014;15(3):178-184.

Published online: 7 January 2014

DOI: https://doi.org/10.4093/jkd.2014.15.3.178

Two Cases of Diabetic Ketoacidosis Associated with Paliperidone Treatment in Schizophrenia

Hyun Ho Kim¹, Hae Kyung Yang^1,², Hyoju Ham¹, Ho Wook Jeon¹, Joon Yub Lee¹, Sea Won Hwang¹, Bo Hyun Jang¹, Gi June Min¹, Jeong Min Lee¹, Seung-Hwan Lee^1,²

¹Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, Seoul, Korea

교신저자: 이승환, 서울시 서초구 반포대로 222 가톨릭대학교 의과대학 내과학교실, 서울성모병원 내분비내과, E-mail: hwanx2@catholic.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Atypical antipsychotics, which have better efficacy and fewer side effects compared to first-generation antipsychotics, are being used increasingly for the treatment of schizophrenia. However, adverse events such as weight gain, diabetes mellitus and abnormal lipid profile have been reported in patients treated with these agents. Diabetic ketoacidosis (DKA) is a rare side effect of atypical antipsychotics, but deserves attention due to its severity. Although various atypical antipsychotics have been reported as causing DKA, there have been no reports showing an association with DKA and paliperidone, which is a recently developed antipsychotic agent. Here, we report two cases of DKA in patients with paliperidone therapy. Both cases had no history of diabetes before use of paliperidone, and DKA was manifested within 2 years of starting paliperidone therapy. Like other atypical antipsychotics, use of paliperidone warrants monitoring for metabolic derangements including DKA.

Keywords: Diabetic ketoacidosis, Paliperidone, Schizophrenia

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Table 1.

Clinical flow chart (Case 1.): Weight, Blood glucose, HbA1C, Insuin, Oral hypoglycemic agent, Antipsychotics

	6 months before	Admission	Discharge	After 1 week	After 1 month	After 3 months	After 5 months
Weight (Kg)	92	84			83		76
Fasting blood glucose (mg/dL)	109	793	90	< 100	< 100	82	87
2-hour Postprandial blood glucose (mg/dL)			120	< 120	< 120	131	< 120
HbA1C (%)		12.2				5.0	5.2
Insulin	No diabetes history	Admission: Continuous insulin infusion			Lantus 36 U once daily	Linagliptin 5 mg once daily
		Discharge: Lantus 40 U once daily			Linagliptin 5 mg once daily	Metformin 850 mg twice daily
Oral hypoglycemic agent		Humalog 10 U before a meals			Metformin 850 mg twice daily	Gliclazide 30 mg twice daily
			Metformin 850 mg twice daily
Antipsychotics	For 2 years, Paliperidone 6 mg/day, orally		Paliperidone Stopped			Paliperidone 6 mg/day, orally re-started

Table 2.

Clinical flow chart (Case 2.): Weight, Blood glucose, HbA1C, Insuin, Oral hypoglycemic agent, Antipsychotics

	3 months before	1 week before	Admission	Discharge	After 1 week	After 2 months	After 5 months	After 5 monts + 2 weeks	After 8 months (re-Admission)	After 8 months + 1 week
Weight (Kg)	99.5	102	97	97.8	96	83	Not Tested	Not Tested	97	Not Tested
Fasting blood glucose (mg/dL)	100	Not Tested	1072	130	145	134	367	250	221	171
2-hour postprandial blood glucose (mg/dL)	Not Tested	Not Tested		120	< 120	< 120	131	300	323	169
HbA1c (%)	5.9		13.3			6.8	11.4		12.0
Insulin	No diabetes history		Admission:		Lantus 54 U, once daily		Lantus 70 U, once daily		Lantus 40 U, once daily
			Continuous insulin infusion		Humalog 8 U, before meals		Humalog 12 U, before meals		Humalog 20-26 U before meals
			Discharge:		Metformin 500 mg,		Pioglitazone 15 mg, once daily		Metformin 500 mg, once daily
Oral hypoglycemic agent			Lantus 46U, once daily		twice daily		> Poor compliance
			Humalog 14-24 U, before meals		> Poor compliance
			Metformin 500 mg, twice daily
	For 3 months
Antipsychotics	Paliperidone 100 mg,		Paliperidone Stopped		Paliperidone 75 mg intramuscular injection
	intramuscular injection

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