Psychotropic Classes Concomitant with Stimulants and the Association with the Risk of Diabetes in Medicaid-Insured Youth

Abstract

Importance:

Psychotropic classes concomitant with stimulants (PCCWS) in children and adolescents have shown an inconsistent impact on the risk of diabetes mellitus. PCCWS with 2–5 classes is common but the risk of diabetes subsequent to stimulant initiation is unknown.

Objective:

To assess the risk of diabetes in youth with PCCWS regimens with 2–5 additional psychotropic classes.

Design:

A retrospective cohort study was conducted using Medicaid claims data from 2007–2014. Youth aged 2–17 years with 1–7.5 years of continuous enrollment who were new stimulant users with clinician-reported psychiatric diagnosis were followed.

Setting:

Outpatient clinic and inpatient records for statewide Medicaid-insured youth in a mid-Atlantic state.

Participants:

The study cohort comprised 30,112 youth with an average follow-up of 6.4 years.

Exposures:

Among stimulant users, five groups were defined according to concomitant use.

Main Outcomes and Measures:

The major outcome is diabetes risk and was assessed using discrete-time failure models, after adjustment for disease risk score which was categorized using more than 120 baseline and time-dependent covariates.

Results:

Among 30,112 new stimulant users, 43 were new diabetes patients and 30,069 were nondiabetes patients. The absolute risk of diabetes in youth had an eight-fold increase from 3 to 5 class PCCWS regimens that included antipsychotics, antidepressants, or anticonvulsant-mood stabilizers (0.5; 1.13; 4.20 per 10,000 person-months, respectively). Compared with stimulant monotherapy, PCCWS with any of these 3 classes were significantly more likely to develop diabetes (adjusted relative risk [ARR], 2.58, (95% CI 1.05–6.82); 5.81, (2.29–14.75); 18.91, (6.07–58.90) for 3, 4 and 5 class PCCWS, respectively). Similarly, there was a significantly greater risk of diabetes for those with 120–779 days of cumulative duration than for shorter exposures, and in 4 and 5 class combined PCCWS including antipsychotics, antidepressants, or anticonvulsant-mood stabilizers [ARR, 3.78, (1.16–12.40)].

Conclusions:

In a large Medicaid-insured, long-enrolled youth cohort, the use of PCCWS, particularly concomitant use with antipsychotic, antidepressant, and/or antipsychotic-mood stabilizers, and with long duration of these combinations were associated with an increased risk of diabetes.

Relevance:

The findings support a call for corroboration in a large national cohort of continuously enrolled Medicaid-insured pediatric youth with long follow-up.