Page 25 - e-book CPG - Bipolar Disorder
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CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)
A 6-week placebo-controlled RCT on adults with bipolar depression demonstrated that 42 mg
A 6-week placebo-controlled RCT on adults with bipolar depression demonstrated that 42 mg
45, level I
of lumateperone, another new AAP, in those with mixed features had:
A 6-week placebo-controlled RCT on adults with bipolar depression demonstrated that 42 mg
45, level I
of lumateperone, another new AAP, in those with mixed features had:
significantly reduced MADRS total scores (LSMD= -4.4, 95% Cl -7.26 to -1.52)
of lumateperone, another new AAP, in those with mixed features had: 45, level I
significantly reduced MADRS total scores (LSMD= -4.4, 95% Cl -7.26 to -1.52)
significantly reduced CGI-S-Bipolar Version-Severity (CGI-BP-S) total scores (LSMD =
significantly reduced MADRS total scores (LSMD= -4.4, 95% Cl -7.26 to -1.52)
significantly reduced CGI-S-Bipolar Version-Severity (CGI-BP-S) total scores (LSMD =
-0.7, 95% Cl -1.43 to -0.05)
significantly reduced CGI-S-Bipolar Version-Severity (CGI-BP-S) total scores (LSMD =
-0.7, 95% Cl -1.43 to -0.05)
higher AEs of somnolence and postural dizziness but no difference in manic switch
-0.7, 95% Cl -1.43 to -0.05)
higher AEs of somnolence and postural dizziness but no difference in manic switch
higher AEs of somnolence and postural dizziness but no difference in manic switch
The summary of the 2021 CANMAT guidelines for the management of BD patients with mixed
42 MAT guidelines for the management of BD patients with mixed
The summary of the 2021 CAN
presentations are as follows:
The summary of the 2021 CANMAT guidelines for the management of BD patients with mixed
presentations are as follows:
42 for first-line treatment based on DSM-5 manic or depressive
there is limited evidence
presentations are as follows: 42
there is limited evidence for first-line treatment based on DSM-5 manic or depressive
episodes with mixed features
there is limited evidence for first-line treatment based on DSM-5 manic or depressive
episodes with mixed features
for DSM-IV-defined mixed episodes, asenapine and aripiprazole are first-line while
episodes with mixed features
for DSM-IV-defined mixed episodes, asenapine and aripiprazole are first-line while
olanzapine (monotherapy or combination), carbamazepine and valproate are second-
for DSM-IV-defined mixed episodes, asenapine and aripiprazole are first-line while
olanzapine (monotherapy or combination), carbamazepine and valproate are second-
line agents
olanzapine (monotherapy or combination), carbamazepine and valproate are second-
line agents
for maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy
line agents
for maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy
or combination) is first-line while lithium and olanzapine are identified as second-line
for maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy
or combination) is first-line while lithium and olanzapine are identified as second-line
options
options
or combination) is first-line while lithium and olanzapine are identified as second-line
b. options
Anxious distress
Anxious distress
b.
Anxious distress is common in BD but often under-recognised by clinicians. Its symptoms
b.
Anxious distress
Anxious distress is common in BD but often under-recognised by clinicians. Its symptoms
include feeling keyed up or tense, feeling unusually restless, difficulty concentrating because
Anxious distress is common in BD but often under-recognised by clinicians. Its symptoms
include feeling keyed up or tense, feeling unusually restless, difficulty concentrating because
of worry, feeling that something awful may happen and feeling that one might lose control.
include feeling keyed up or tense, feeling unusually restless, difficulty concentrating because
of worry, feeling that something awful may happen and feeling that one might lose control.
Prompt evaluation and treatment of its symptoms is important as it is associated with adverse
of worry, feeling that something awful may happen and feeling that one might lose control.
Prompt evaluation and treatment of its symptoms is important as it is associated with adverse
outcomes including higher suicidal risk and persistence of bipolar symptoms compared with
Prompt evaluation and treatment of its symptoms is important as it is associated with adverse
outcomes including higher suicidal risk and persistence of bipolar symptoms compared with
those without anxious distress.
outcomes including higher suicidal risk and persistence of bipolar symptoms compared with
those without anxious distress.
those without anxious distress.
A meta-analysis evaluating the effectiveness of pharmacotherapy vs placebo on BD patients
A meta-analysis evaluating the effectiveness of pharmacotherapy vs placeb
(mostly in depressive episodes) with anxiety symptoms revealed that:
A meta-analysis evaluating the effectiveness of pharmacotherapy vs placebo on BD patients
(mostly in depressive episodes) with anxiety symptoms revealed that:
46, level I
pharmacotherapy (primarily AAPs - cariprazine, quetiapine, olanzapine and olanzapine-
46, level I
(mostly in depressive episodes) with anxiety symptoms revealed that: 46, level I o on BD patients
pharmacotherapy (primarily AAPs - cariprazine, quetiapine, olanzapine and olanzapine-
fluoxetine combination) was more effective based on improvement of scores in
pharmacotherapy (primarily AAPs - cariprazine, quetiapine, olanzapine and olanzapine-
fluoxetine combination) was more effective based on improvement of scores in
Generalized Anxiety Disorder-7 scale (GAD-7) or Hospital Anxiety and Depression scale
fluoxetine combination) was more effective based on improvement of scores in
Generalized Anxiety Disorder-7 scale (GAD-7) or Hospital Anxiety and Depression scale
(HADS) (SMD= -0.22, 95% CI -0.34 to -0.11) and the result remained significant even
Generalized Anxiety Disorder-7 scale (GAD-7) or Hospital Anxiety and Depression scale
(HADS) (SMD= -0.22, 95% CI -0.34 to -0.11) and the result remained significant even
after controlling depressive symptoms (SMD= -0.15, 95% CI -0.28 to -0.02)
(HADS) (SMD= -0.22, 95% CI -0.34 to -0.11) and the result remained significant even
after controlling depressive symptoms (SMD= -0.15, 95% CI -0.28 to -0.02)
NS difference in all-cause discontinuation rate
after controlling depressive symptoms (SMD= -0.15, 95% CI -0.28 to -0.02)
NS difference in all-cause discontinuation rate
A total of 32 out of 37 RCTs had moderate to strong quality based on assessment with
NS difference in all-cause discontinuation rate
A total of 32 out of 37 RCTs had moderate to strong quality based on assessment with
Effective Public Health Practice Project Quality Assessment Tool.
A total of 32 out of 37 RCTs had moderate to strong quality based on assessment with
Effective Public Health Practice Project Quality Assessment Tool.
Effective Public Health Practice Project Quality Assessment Tool.
CANMAT guidelines state that quetiapine, olanzapine-fluoxetine combination and lurasidone
CANMAT guidelines state that quetiapine, olanzapine-fluoxetine combination and lurasidone
40
improve anxiety symptoms associated with bipolar depression.
CANMAT guidelines state that quetiapine, olanzapine-fluoxetine combination and lurasidone
improve anxiety symptoms associated with bipolar depression.
40
improve anxiety symptoms associated with bipolar depression.
40
c.
Rapid cycling
c.
Rapid cycling
Patients who experience at least four episodes (meeting criteria for full mania, hypomania or
c.
Rapid cycling
Patients who experience at least four episodes (meeting criteria for full mania, hypomania or
major depression) during a 12-month period are classified in DSM-5 as “rapid cycling”. The
Patients who experience at least four episodes (meeting criteria for full mania, hypomania or
major depression) during a 12-month period are classified in DSM-5 as “rapid cycling”. The
lifetime prevalence of rapid cycling is between 26% and 43% of those with BD. Patients with
47
major depression) during a 12-month period are classified in DSM-5 as “rapid cycling”. The
lifetime prevalence of rapid cycling is between 26% and 43% of those with BD. Patients with
47higher risk at
this condition are more likely to demonstrate greater severity of illness and,
lifetime prevalence of rapid cycling is between 26% and 43% of those with BD. Patients with
this condition are more likely to demonstrate greater severity of illness and, higher risk
suicide attempts and functional impairment compared with non-rapid cycling patients.
this condition are more likely to demonstrate greater severity of illness and, higher risk at
suicide attempts and functional impairment compared with non-rapid cycling patients.
48
Successful treatment of rapid cycling often requires several combinations of mood-stabilising
48
suicide attempts and functional impairment compared with non-rapid cycling patients.
Successful treatment of rapid cycling often requires several combinations of mood-stabilising
agents.
Successful treatment of rapid cycling often requires several combinations of mood-stabilising
agents.
agents.
A recent meta-analysis on mood stabilisers for treatment of rapid cycling BD showed the
A recent meta-analysis on mood stabilisers for treatment of rapid cycling BD showed the
following:
A recent meta-analysis on mood stabilisers for treatment of rapid cycling BD showed the
following:
49, level I
combination of lamotrigine and lithium compared to lithium monotherapy reported:
49, level I
following: 49, level I 47 48 at
combination of lamotrigine and lithium compared to lithium monotherapy reported:
combination of lamotrigine and lithium compared to lithium monotherapy reported:
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