Page 28 - e-book CPG - Bipolar Disorder

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

Studied Lower risk ratio of Lower risk ratio of Lower risk ratio of
Lower risk ratio of
Lower risk ratio of
Studied
Lower risk ratio of
relapse into
medications relapse into any mood relapse into relapse into
relapse into any mood relapse into
medications
episode (from lowest manic/hypomanic/ depressive episode
manic/hypomanic/
depressive episode
episode (from lowest
to highest) mixed episode (from (from lowest to
(from lowest to
mixed episode (from
to highest)
highest)
lowest to highest)
lowest to highest) highest)
First NMA  Asenapine  Asenapine  Aripiprazole +
First NMA
 Aripiprazole +
 Asenapine
 Asenapine
(included  Aripiprazole +  Lithium + valproate
valproate
(included
 Lithium +
 Aripiprazole +
monotherapy valproate oxcarbazepine  Lamotrigine +
 Lamotrigine +
monotherapy
valproate
oxcarbazepine
and
and  Lithium +  Aripiprazole LAI valproate
valproate
 Aripiprazole LAI
 Lithium +
combination oxcarbazepine  Olanzapine,  Quetiapine
combination
oxcarbazepine
 Quetiapine
 Olanzapine,
therapy in
therapy in  Olanzapine  Risperidone LAI  Lamotrigine
 Olanzapine
 Lamotrigine
 Risperidone LAI
which two
which two  Aripiprazole LAI  Lithium + valproate  Olanzapine
 Aripiprazole LAI
 Olanzapine
 Lithium + valproate
drugs used
drugs used  Lithium + valproate  Aripiprazole  Lithium
 Lithium + valproate
 Lithium
 Aripiprazole
were
were  Quetiapine  Aripiprazole +
 Quetiapine
 Aripiprazole +
specified)
specified)  Aripiprazole + lamotrigine
 Aripiprazole +
lamotrigine
lamotrigine  Lithium
lamotrigine
 Aripiprazole  Lithium
 Aripiprazole
 Quetiapine,
 Lithium  Quetiapine,
 Paliperidone
 Lithium  Paliperidone
 Valproate
 Valproate
 Valproate  Valproate
 Risperidone LAI

 Risperidone LAI
 Lamotrigine
 Lamotrigine

Second NMA  Quetiapine + lithium or  Aripiprazole + lithium  Lurasidone + lithium or
Second NMA  Quetiapine + lithium or  Aripiprazole + lithium  Lurasidone + lithium or
valproate
valproate
or valproate
(included
valproate
valproate
or valproate
(included  Lurasidone + lithium  Quetiapine + lithium or  Quetiapine + lithium or
combination
combination  Lurasidone + lithium  Quetiapine + lithium or  Quetiapine + lithium or
valproate
or valproate
valproate
therapy of
or valproate
therapy of  Aripiprazole + lithium valproate valproate
SGAs and
SGAs and  Aripiprazole + lithium
or valproate
lithium or
or valproate
lithium or  Ziprasidone + lithium
valproate
valproate  Ziprasidone + lithium
or valproate
comparing
comparing or valproate
with placebo
with placebo
and lithium or
and lithium or
valproate)
valproate)

 only asenapine, quetiapine, olanzapine, valproate, lithium monotherapy and
combination of lurasidone or quetiapine + lithium or valproate had lower all-cause
 only asenapine, quetiapine, olanzapine, valproate, lithium monotherapy and
discontinuation rate
combination of lurasidone or quetiapine + lithium or valproate had lower all-cause
 significant AEs reported were:
discontinuation rate
o lithium and valproate had higher risk of EPS and nausea
 significant AEs reported were:
o olanzapine had higher risk of somnolence
o lithium and valproate had higher risk of EPS and nausea
o risperidone LAI had higher risk of hyperprolactinaemia
o olanzapine had higher risk of somnolence
o quetiapine had higher risk of dry mouth
o risperidone LAI had higher risk of hyperprolactinaemia
o lithium had higher risk of diarrhoea
o quetiapine had higher risk of dry mouth
Most of the RCTs assessed had low to moderate risk of bias based on Cochrane RoB
o lithium had higher risk of diarrhoea

Most of the RCTs assessed had low to moderate risk of bias based on Cochrane RoB
In a meta-analysis of 11 RCTs on long-term effectiveness and safety of antidepressants in BD
(treatment duration ranged up from 4.4 to 36 months), the findings were: 51, level I
In a meta-analysis of 11 RCTs on long-term effectiveness and safety of antidepressants in BD
 combination of antidepressants with mood stabilisers was more effective than mood
(treatment duration ranged up from 4.4 to 36 months), the findings were: 51, level I
stabilisers and placebo for prophylaxis of new depressive episodes (RR=0.66, 95% CI
 combination of antidepressants with mood stabilisers was more effective than mood
0.47 to 0.93; NNT=12.5), without significant increased risk of new manic/hypomanic
stabilisers and placebo for prophylaxis of new depressive episodes (RR=0.66, 95% CI
episodes
0.47 to 0.93; NNT=12.5), without significant increased risk of new manic/hypomanic
episodes
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