Me d i c a t i o n s F o r T h e P h a s e s O f B i p o l a r D i s o r d e r
Lithium
Medication:
Bipolar FDA
Indication
(Other evidence of
efficacy in Bipolar)
Do si ng
A cu i t y
( t i me t o o n set )
S i d e Ef f e c t s
Ease of Use
(monitoring)
Lamotrigine
(Lamictal)
Valproate
( D e p a k o te a n d
Depakote ER)
Carbamazepine/
Ox c a r b a z e p i n e ,
(T e g r e t o l ,
Trileptal)
( Eskalit h,
L i t h o b id ,
L it h iu m
car b o n at e )
Maintenance
Mania
Only Equetro for Mania,
otherwise none
Maintenance, Mania
Depression
Maintenance
Possibly Maintenance
Possibly depression
Carbamazepine dose
r ange commonly 8001200 mg/day (divided
bid); Oxcarbazepine dose
range commonly 12002400 mg/d (divided bid)
Doses often 6001200mg/day (usually
divided bid);
Maximum 1800mg/day;
Often started at 300 mg
twice daily
A few weeks
Taper up very slowly
per manufacturer;
Dose is usually
200mg/day (given
once daily);
OCs ↓ levels by 50%
Dose range often
1000-2000 mg/day
(commonly divided bid);
Maximum 60 mg/kg/day;
Start 250-1000 mg/day
depending on acuteness
Several weeks to 6
weeks
Can see improvement within
1 week if aggressive dosing
A few weeks
Life-threatening rash
(1/1000), suicidal
thoughts, rash, nausea,
vomiting, insomnia,
fatigue, dry mouth,
constipation
Suicidal thoughts, weight
gain, hair loss, tremor,
sedation, G.I. upset,
hematologic changes,
PCOS;
rare hepatitis, pancreatitis,
rare hyperammonemia
without Hepatitis
Serious dermatologic
reactions (esp. Asians),
suicidal thoughts,
dizziness, ataxia,
drowsiness, nausea,
vomiting, blurred vision,
low serum sodium;
rare agranulocytosis
(carbamazepine)
Carbamazepine: Trough
4-12 mcg/ml (based on
seizure literature); Monitor
CBC, LFTs, thyroid, kidney
and repeat CBC
frequently; Monitor bone
density
Trough 50-125mcg/ml
Labs not necessary; (based on seizure
Monitor bone density? literature); Monitor
weight/BMI, LFTs,
platelets; Consider coags
before surgery; Monitor
bone density
Consider: PhASE Phase of bipolar illness, Acuity, Side effects, Ease of use of the medication
Increased thirst and urination,
weight gain, cognitive dulling,
confusion, fine tremor, G.I.
irritation, hypothyroidism or
euthyroid goiter; Toxicity:
May also see blurred vision,
tinnitus, diabetes insipidus,
ataxia, ms. weakness,
seizure, EKG changes
Exactly 12 hr. trough level is
important;
.6-1.2 mmol/L
maintenance; Toxic >1.5
mmol/L; Monitor kidney,
thyroid; Educate: stop if
dehydrated
Seco n d
Gen er at i o n
Antipsychotics
( s e e A P Ta b l e )
Mania (all)
See AP table for others
See separate antipsychotic
table
See separate antipsychotic
table
Can improve mania within 1
week
See separate antipsychotic
table
See separate antipsychotic
table
Copyright Karen Blackman, MD
Michigan State University, Spring 2010
Email karen.blackman@hc.msu.edu
Edited 6/3/2011 Peter Koopman,MD
Second Generation An t i p s y c h o t i c s I n Bi p o l a r Di s o r d e r
Atypical
Antipsychotic
Bipolar FDA
Indication
Dosing
(for healthy nonelderly adults;
Peds, if
indicated,
dosed separately)
Acuity
( t i m e t o o ns e t )
Side Effects
Ease of use
(monitoring)
Aripiprazole
(Abilify)
Olanzapine
(Zyprexa)
Risperidone
(Risperdal)
Quetiapine
(Seroquel)
Ziprasidone
(Geodon)
Asenapine
(Saphris)
Mania/Mixed,
Maintenance,
Acute Agitation,
Peds: Mania/Mixed
Mania/Mixed,
Maintenance,
Acute Agitation,
Peds: Mania/Mixed
Mania/Mixed
Peds: Mania/Mixed
Mania
Bipolar Depression,
Maintenance (adjunct)
Peds: Mania
Mania/Mixed
Mania/Mixed
Acute Mania: Dose
range 15-30 mg/day;
Recommended start
dose is 7.5 mg/day
Acute Agitation:
5.25-15 mg IM X1; May
repeat; Read
manufacturer info for
timing; Max 30 mg/day
Pediatric Mania:
(Ages 10-17)
Dose range is
2–30 mg/day;
Recommended starting
dose is 2 mg/day for 2
days, then 5 mg/day
for 2 days, then adjust
by 5 mg increments
Acute Mania:
Dose range is
5-20 mg/day;
Recommended start
dose is 10-15 mg/day
Acute Mania:
Dose range is 1-6
mg/day (qd or bid);
Recommended start
dose is 2-3 mg/day
Acute Agitation:
2.5 - 10 mg IM X1; May
repeat; Read
manufacturer info for
timing; Max 30 mg/day
Pediatric Mania:
(Ages 10-17) Dose
range is 0.5 to
6mg daily; Start 0.5
mg/day; adjust dose by
0.5-1 mg/day at
intervals of at least 24
hours; Maximum dose
is 6 mg/day (increased
efficacy not shown
over 2.5 mg/day)
Acute Mania:
Dose range is 200-400
mg bid (total daily
dose of 400-800 mg);
Recommended start
dose is 50 mg bid
Bipolar Depression:
50 mg qhs x1,
100 mg qhs x1,
200 mg qhsx1, then,
300 mg qhs Maximum
dose is 600 mg qhs
Pediatric Mania: (Ages
10-17) Recommended
dosing is start 25 mg bid
X 1 day, 50 mg bid X1
day, then increase by
100 mg/day
Acute Mania:
Dose range is 40-80
mg bid (total daily dose
of 80-160 mg);
Recommended start
dose is 40 mg bid;
Increase to 60-80 mg
bid on day 2; Maximum
dose 80 mg bid;
TAKE WITH FOOD!
(Blood levels
significantly reduced
otherwise)
Pediatric Mania:
(Ages 13-17)
Dose range is
2.5 – 20 mg/day; (Not
first line due to
metabolic side effects)
Acute Mania:
10 mg SL bid; decrease by
50% if not tolerated; do not
cut, crush, or chew
May improve psychotic and manic symptoms within one week;
Those indicated for Bipolar Depression may work more rapidly than AEDs or Lithium, especially if latter are cautiously dosed
“Neurologic and Metabolic sx: tremor, restlessness, unwanted movements, stiffness; Increases in weight, blood pressure, lipids,
sugar (DM);
Neuroleptic Malignant Syndrome: uncommon with atypicals (.2%) but does occur;
Somnolence, dizziness, dry mouth, hypotension, sex. dysfunction, lowering seizure threshold, hyperprolactemia (esp risperidone), leukopenia
Weight Gain: Olanzapine > Quetiapine > Risperidone >.Aripiprazole+Ziprasidone
Monitor BMI, Fasting Glucose, Lipids, Neurologic symptoms and CBC frequently during initial treatment if leukopenia/neutropenia history
Consider: PhASE Phase of bipolar illness, Acuity, Side effects, Ease of use of the medication
Copyright Karen Blackman,
Michigan State University,Spring 2010
Email karen.blackman@hc.msu.edu
Edited 6/3/2011 Peter Koopman, MD