Page 24 - e-book CPG - Bipolar Disorder

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)

Phases of BD Mania/hypomania with Depression with mixed
mixed features features
Acute episode
First-line
Monotherapy Olanzapine, aripiprazole, Lurasidone, olanzapine,
asenapine, paliperidone, quetiapine, valproate

Combination therapy Olanzapine + valproate Lurasidone + valproate
Olanzapine + lithium Lurasidone + lithium
Quetiapine + lithium Olanzapine + valproate
Quetiapine + valproate Olanzapine + lithium
Asenapine + valproate Olanzapine/fluoxetine
Aripiprazole + valproate combination (OFC)
Ziprasidone + treatment as
usual

Second-line Cariprazine, ziprasidone, Aripiprazole, asenapine,
risperidone, clozapine, carbamazepine
valproate, lamotrigine,
carbamazepine
Maintenance
First-line
Monotherapy Lithium, valproate, olanzapine, quetiapine
Combination therapy Quetiapine + valproate
Quetiapine + lithium
Aripiprazole + valproate
Aripiprazole + lithium

Second-line Ziprasidone
Risperidone + lithium
Risperidone + valproate
Aripiprazole + lamotrigine

The same review recommended that antidepressants should be avoided in mixed episodes.
Clozapine was an effective option in treatment-resistant patients.
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A systematic review on adults with BD showed that in those with mixed episodes: 30, level I
 combination of olanzapine plus lithium or valproate was effective in acute episodes but
combination of haloperidol or risperidone plus lithium or valproate was not
 combination of quetiapine plus lithium or valproate was effective in preventing relapse
but the addition of aripiprazole on lithium or valproate was not
 lithium monotherapy was not effective in preventing relapse
Quality assessment of primary papers however was not mentioned.

A post-hoc analysis of three RCTs on acute bipolar depression with concurrent manic
symptoms compared the effectiveness of cariprazine (1.5 mg and 3 mg) vs placebo at six
weeks and showed that the former had: 44, level I
 significantly more improvement of MADRS total score, CGI-S and HAM-D scores
 significantly higher response and remission rates
 NS improvement of YMRS total score

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