People with schizophrenia die 15–20 years earlier than the general population, mostly from cardiovascular disease. Metabolic monitoring is the GP's most important share-care contribution — co-commence metformin with olanzapine or clozapine.
Metabolic monitoring schedule
- Baseline: weight, BP and waist circumference; fasting glucose, HbA1c and lipids; ECG; prolactin if risperidone.
- Week 4: weight and BP; fasting glucose; side-effect review.
- Week 12: full metabolic panel (weight, BP, glucose, HbA1c, lipids); repeat ECG if the dose has changed.
- 6-monthly: weight, BP and waist circumference; glucose, HbA1c and lipids; mental health review.
- Annually: full physical assessment and metabolic panel, plus cervical screening, dental review, vaccinations and smoking status.
Emerging: GLP-1 for metabolic risk. GLP-1 receptor agonists are increasingly used adjunctively for antipsychotic-associated weight gain, per the 2025 INTEGRATE schizophrenia pharmacotherapy algorithm (Lancet Psychiatry). Evidence is still emerging and PBS access for this indication is limited — discuss eligibility with the treating psychiatrist if metabolic risk persists despite lifestyle measures and metformin.
Critical side effects
- Neuroleptic malignant syndrome: fever, rigidity, autonomic instability, raised CK → EMERGENCY, send to ED.
- Acute dystonia: sudden muscle spasms (jaw, eyes, neck) — give IM benztropine 1–2mg.
- Akathisia: inner restlessness, often misread as agitation — reduce the dose or consider propranolol.
- Tardive dyskinesia: late-onset involuntary movements, often irreversible — refer to psychiatry.
- Clozapine agranulocytosis: sore throat or fever → urgent FBC; cease if neutropenia.
- QT prolongation: especially with ziprasidone or IV haloperidol — baseline and interval ECG.
Clozapine & LAI share-care
- FBC monitoring (Australian schedule): weekly for the first 18 weeks, then 4-weekly for the duration of treatment, via the mandatory clozapine patient monitoring registry.
- Other clozapine risks: myocarditis (mostly in the first month — check local protocol for baseline/interval troponin and CRP), seizures, sialorrhoea, and constipation (can be fatal if it progresses to bowel obstruction).
- Long-acting injectables: aripiprazole, paliperidone, risperidone and olanzapine are available as LAIs — improve adherence and reduce relapse; confirm current PBS authority requirements at pbs.gov.au.
Safety
- Suspected NMS is a medical emergency — stop the antipsychotic and arrange immediate ED transfer.
- Any sore throat or fever on clozapine needs an urgent FBC — don't wait for the scheduled monitoring date.
- Clozapine-associated constipation can progress to bowel obstruction and death — ask about it proactively and treat early.
Red flags / refer
- Tardive dyskinesia suspected → refer to psychiatry; often only partially reversible.
- Rising HbA1c, weight gain over 7% of baseline, or new dyslipidaemia → co-manage with metformin and lifestyle support, looping in psychiatry.
- Considering clozapine after 2 failed trials → psychiatry referral for work-up and registry enrolment.
MH-04B v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Framework: RANZCP/ANZJP GRADE Schizophrenia Guideline (2026); clozapine FBC schedule per NIMC/ACSQHC. Companion sheet: MH-04A Psychosis — Recognition & Treatment.
