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Bipolar disorder: Recommended agents and dosing

Table 3.3: Recommended agents and dosing in bipolar disorder

 
treatment dosing laboratory measures common treat-ment-emergent adverse events*
Antiepileptic agents      
Divalproex

Initiation:

500 – 1000 mg QHS; dosing based on 12 hrs trough plasma level (350 – 700 mmol/L)

Pre-treatment: CBC, electrolytes, TSH, liver function tests. Assure contraceptive being used (teratol- ogy risk); menstrual history required (i.e.,

DVPX associated with polycystic ovarian syndrome); repeat blood work including VPA level Q6 months if stable.
Sedation, somno- lence, weight gain, menstrual irregu- larities, alopecia, tremor.
Lithium

Initiation

600 – 900 mg QHS; dosing based on 12 hrs trough plasma levels (0.8 –

1.2 meq/L;

acute mania;

0.6 – 0.8 meq/L; maintenance/ depression)

Pre-treatment: CBC; electrolytes (including Ca++), TSH, BUN, cre- atinine. (EKG >40 yrs, or established heart disease/risk factors). Maintenance: lithium level: CBC; electrolytes (including Ca++),

TSH, BUN, creatinine. Q6 months if stable. More frequently if symptomatic.
Sedation, cognitive dulling, weight gain, dermatological reac- tions (e.g., acne, eczema), polyurea, polydipsia, tremor.
Carbamaze- pine

Initiation:

600 – 900 mg; titrate as toler- ated. 600 –

1200 mg.
Pre-treatment: same as above for dival- proex; CBZ not asso- ciated with PCOS. Sedation, som- nolence, slurred speech, confusion, tremor.
Lamotrigine Initiation: 25 mg Q2 weeks then 50 mg Q2 weeks followed by 100 – 300 mg daily. CBC, electrolytes, no LTG levels required. Repeat Q6 months. Headaches, gastrointestinal, dizziness, benign rash (10 per cent); serious rash (i.e., Stevens-Johnson syndrome; 1:1000).
Gabapentin

Initiation:

600 – 900 mg. Maintenance:

900 – 4000 mg in divided doses. Increase as tolerated

Q2 weeks.
Same as lamotrigine. Sedation, somnolence, confusion.
Topiramate

Initiation:

50 mg

Maintenance:

100 – 300 mg. Titrate Q2 weeks as tolerated.
Same as lamotrigine. Include HCO3. Cognitive dulling, word-finding diffi- culties, weight loss, metabolic acidosis, intensification of glaucoma.
Oxcarbaze- pine

Initiation:

150 – 300 mg. Maintenance:

300 – 1500 mg.
Same as carbamazepine. Same as carbamazepine.
Novel antipsychotic drugs      
Olanzapine

Initiation:

10 – 15 mg. Maintenance:

5 – 20 mg. Higher dosing in mania.

Pre-treatment: weight, BMI, fasting blood glucose, lipid frac- tionation, LFT, CBC, electrolytes. Repeat

Q6 months. Repeat metabolic parameters more frequently in patients gaining weight.
Extrapyramidal symptoms (EPS), weight gain, dysgly- cemia, metabolic syndrome, seda- tion, somnolence, transient LFT elevation.
Risperidone

Initiation: 1 – 2 mg with a target of between

3 and 6 mg per day.
Same as olanzapine. Same as olanzap- ine. LFT elevation not typically seen. Prolactin elevation/ prolactin- related side-effects.
Quetiapine

Initiation:

300 – 600 mg acute mania;

150 – 300 mg for acute depres- sion; 150 – 450 mg mainte- nance in most patients. Titrate as tolerated

(i.e., achieve recommended dose within

1 – 2 weeks); Quetiapine  XR initiate 200 mg; increase to

300 – 600 mg in 2 days.
Same as olanzapine. Same as olanzap- ine. LFT elevation not typically seen.
Ziprasidone

Initiation:

60 – 120 mg. Maintenance:

60 – 160 mg. Titrate as tole- rated.
Same as olanzapine, EKG. EPS, tremor, agitation, greater propensity to pro- long QT interval. Akathesia, restless- ness, minimal weight gain, meta- bolic disruption.
Aripiprazole

Initiation: 2.5 –

20 mg for acute. Maintenance:

2.5 – 30 mg. Titrate as tolerated.
Same as olanzapine. Same as ziprasidone.
Novel antidepressants      
SSRIs, SNRIs, NaSSAs

Covered in antidepressant section. (See Table 2.1: "First- line antidepres- sant medica- tions, doses

and profiles"

in chapter 2.)
  Mobilization of hypo/mania and rapid cycling.
 

 


* No treatment for bipolar disorder is established as safe during pregnancy. Disparate teratogenetic effects are ascribed to each agent. Neural tube defects is the most replicated finding with divalproex and carbamazepine. Available safety data also suggest possible oral cleft defect with lamotrigine. Contraceptive methods with all bipolar treatments is recommended. In Canada, see Motherisk (www.motherisk.org/women/index.jsp) for more details regarding these and other agents.