GNYHA PSYCKES Quality Collaborative 
Antipsychotic Medications Posing a Risk of Cardiometabolic Side Effects
NEW STARTS CHECKLIST
To be completed before initiation of any
antipsychotic medication posing a moderate or high risk of cardiometabolic side effects.
For adults: olanzapine, quetiapine, chlorpromazine, thioridazine.
For children/adolescents: ALL antipsychotics EXCEPT aripiprazole and ziprasidone.
	 Col A   Col B		
1	No    Yes  	Does the client report a diagnosis of any cardiometabolic condition (including diabetes, pre-diabetes, high triglycerides, low HDL, hypertension, obesity and/or cardiovascular disease)?	
2	No    Yes  	Is the client taking any medication used to treat the above conditions?	
3	No    Yes  	Is there documentation indicating that the client has any of the above conditions, in the medical record (and/or in PSYCKES, if applicable)?	
4	Yes   No 
	Have you obtained a family history of cardiometabolic conditions and ischemic vascular disease, including age at onset?	
5	Do you have the results of the following diagnostic tests for the client, dated within the past 6 months (or as clinically appropriate)? 	
	Yes   No  	Fasting glucose level	
	Yes   No  	Fasting triglyceride levels / fasting HDL cholesterol level	
	Yes   No  	Waist circumference / BMI	
	Yes   No  	Blood pressure	
	Yes   No  	ECG (if indicated)	
6	Based on all of the above data sources, is the client diagnosed with / being treated for / exhibiting signs and symptoms of any of the following?	
	No    Yes  	Diabetes?	
	No    Yes  	Pre-diabetes?	
	No    Yes  	Hypertriglyceridemia?	
	No    Yes  	Obesity?	
	No    Yes  	Hypertension?	
	No    Yes  	Ischemic Vascular Disease (cardiovascular/ cerebrovascular/ peripheral vascular)?	
	No    Yes
	Metabolic syndrome?
	
	No    Yes    	Strong family history of diabetes and/or ischemic vascular disease with early onset?	
	If you answered “No” to all items in question #6, then STOP, you have completed this form.
If you have answered “Yes” to any items in question #6, please continue with this form.	
7	Yes   No  	Does the client have a psychotic disorder?				
If yes, skip to # 9	
8	Yes   No 
   (Check No if 
      unknown)
If yes, specify 	(If no psychotic disorder) Has the client had adequate trials of: (1) a medication other than an antipsychotic, (2) an evidence-based psychosocial treatment AND (3) an antipsychotic that is in the low risk category for metabolic side effects?  If yes, please specify:	
9	Yes   No 
   (Check No if 
      unknown)
If yes, specify 	(If the client has a psychotic disorder) Has the client had a trial of at least ONE medication (for children: one non-antipsychotic medication) that is in the low risk category for cardiometabolic side effects at an adequate dose for an adequate period of time?  If yes, please specify:__________________________	
10	No    Yes  	Are there safer medications that may be effective?	
	If any boxes in Column B above are checked, please consult with the Program Director/ Medical Director before recommending a course of a moderate- or high-risk antipsychotic medication.  In addition, before initiating the medication regimen, please complete the following steps:	
11	Yes   No  	Have the benefits and risks of the proposed regimen, including cardiometabolic risk, been discussed with the client, family and/or legal guardian, as appropriate?	
12	Yes   No  	Is the rationale for this medication regimen clearly documented in the chart?	
13	Yes   No  	(For children only) Is there a plan to provide concurrent psychosocial treatment? Specify provider(s) and frequency:____________________________________________________
	
14	Yes   No  	Is there a plan to monitor the client regularly for changes in cardiometabolic indicators in accordance with the protocol below?  Specify provider(s) and frequency:

Page 1 of 2 				     Revised 12/9/2010

New Starts Checklist, Page 2 of 2
American Diabetes Association
Consensus Monitoring Protocol for Individuals on Second Generation Antipsychotics*
	Baseline	4 Weeks	8 Weeks	12 Weeks	Quarterly	Annually	Every 5 Yrs	
Personal/family history	X					X		
Weight (BMI)	X	X	X	X	X			
Waist circumference	X					X		
Blood pressure	X			X		X		
Fasting plasma glucose	X			X		X		
Fasting lipid profile	X			X			X	
*More frequent assessments may be warranted based on clinical status	
J Clin Psychiatry 65:2, February 2004