BackgroundAdjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin’s place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.ObjectiveTo produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.MethodsA list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be ‘adopted or adapted’ from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008–2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.FindingsWe confirmed that no published guideline—of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.ConclusionAll 11 recommendations and 7 supporting good practice developed here were formulated de novo.Clinical implicationsThese recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

<b><i>Background:</i></b> This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity. <b><i>Summary:</i></b> It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients’ lived experiences; move beyond simplistic approaches of “eat less, move more” and address the root drivers of obesity. <b><i>Key Messages:</i></b> People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.

Background: Antipsychotics are associated with a range of side-effects that can influence patients’ subjective well-being negatively resulting in poor adherence. In order to limit the negative consequences of side-effects, they should be regularly systematically assessed. The aim of this study was to systematically assess antipsychotic side-effects in an inpatient cohort using validated rating scales. Methods: Eligible individuals prescribed an antipsychotic for at least 2 weeks were invited to have their side-effects assessed systematically. Results: A total of 208 individuals were assessed systematically for antipsychotic side-effects; 71.5% ( n = 138) stated that they had not reported side-effects to their clinician prior to the assessment. The most commonly reported side-effects were daytime drowsiness (75%), dry mouth (58.2%) and weight gain (50.0%), while the most distressing side-effects reported were erectile dysfunction (35.0%), sexual dysfunction (26.3%) and amenorrhoea (26.3%). There was no evidence of an association between side-effect severity/number of side-effects reported/distress caused by those taking high dose/combination antipsychotics versus standard dose monotherapy. Conclusion: Side-effects must be regularly and systematically assessed using a validated rating scale. As distress caused by side-effects plays a major role in non-adherence, assessment should examine distress and data on distressing side-effects should be available to those choosing an antipsychotic. Given the lack of correlation between high dose/combination antipsychotics and side-effects, treatment should be tailored to the individual based on response/tolerance and dose reduction/avoidance of polypharmacy should not be recommended to minimise side-effects.

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<p><strong>Background:</strong> One significant complexity associated with management of antipsychotic-induced weight gain (AIWG) is extensive interindividual variability amongst patients in initial susceptibility to AIWG, time to plateau of weight gain, and resultant final amount of weight gained. Prior to antipsychotic commencement, risk-stratified information highlighting those at increased risk of experiencing significant AIWG would allow tailored weight monitoring and subsequent management protocols to be developed.</p><p><strong>Methods: </strong>This protocol is for a planned systematic review to identify the current utility of baseline clinical, sociodemographic, and biological prognostic factors in predicting the likelihood of significant AIWG occurring prior to antipsychotic commencement. The cohort assessed will be antipsychotic-naïve adults with a first episode of psychosis. Searches for both randomised and prospective non-randomised studies will be undertaken by searching four electronic databases and two trial registers, followed by reference searching, forward citation searching and liaison with content experts. A meta-analysis of study results will be undertaken where study quality and homogeneity allow. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework modified for prognostic research will be used to assess evidence certainty. This protocol was prepared in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols guideline and latest guidance from the Prognosis Methods Group of the Cochrane Collaboration.</p><p><strong>Results: </strong>This review will establish the current quantity, quality and clinical utility of evidence addressing the prognostic association of clinical, biological, and sociodemographic factors in prospectively identifying those more likely to experience significant AIWG.</p><p><strong>Registration details:</strong> PROSPERO registration number CRD42021258148.</p>