Page 29 - e-book CPG - Bipolar Disorder
P. 29
CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)
compared with mood stabiliser monotherapy, antidepressant monotherapy was not
superior in preventing new depressive episodes but had an increased risk of new
mania/hypomania episodes (RR=2.35, 95% CI 1.42 to 3.91; NNH=4.3)
m
ep
as
ap
h
t
r
essa
oo
t
a
ab
s
m
no
ntid
d
r
other
ap
m
on
o
he
t
t
w
on
i
w
n
compared
y
i
ser
i
l
,
y
compared with mood stabiliser monotherapy, antidepressant monotherapy was not t
compared with mood stabiliser monotherapy, antidepressant monotherapy was not
In the subgroup analysis on the prevention of depressive episodes, patients with BD II
ep
sup
ne
superior in preventing new depressive episodes but had an increased risk of new
bu
erio
ng
i
r
w
t
n
e
en
de
pr
d
ha
ev
an
i
t
r
f
sk
o
i
ncreased
n
i
i
ew
sod
es
pressi
v
compared with mood stabiliser monotherapy, antidepressant monotherapy was not
superior in preventing new depressive episodes but had an increased risk of new
po
35
es (
a epi
=2
=4
2 t
R
i
an
1.4
m
95
.
R
;
N
3.91
.
I
3)
m
o
mania/hypomania episodes (RR=2.35, 95% CI 1.42 to 3.91; NNH=4.3)
,
a/hy
%
N
C
an
benefited significantly with antidepressants (used as combination or monotherapy) at long-
sod
H
i
superior in preventing new depressive episodes but had an increased risk of new
mania/hypomania episodes (RR=2.35, 95% CI 1.42 to 3.91; NNH=4.3)
f
an
p
de
sub
i
t
es,
he
o
group
term but not those with BD I. Apart from that, only second-generation antidepressants were II In compared with almood stabiliser monotherapy, antidepressant monotherapy was not
i
atie
t
In the subgroup analysis on the prevention of depressive episodes, patients with BD II
on
w
sod
h
i
nts
s
si
t
v
D
t
y
e
B
en
he
prev
ep
pressi
on
mania/hypomania episodes (RR=2.35, 95% CI 1.42 to 3.91; NNH=4.3)
In the subgroup analysis on the prevention of depressive episodes, patients with BD g -
found to be significantly effective. Three out of 11 RCTs had high risk of bias based on II
bi
l
ni
u
en
on
i
ap
increased risk of new
h
t
si
m
an
t
b
m
ed
t
i
benefited significantly with antidepressants (used as combination or monotherapy) at long-
g
r
o
can
other
as
na
i
s
t
i
e
i
onan
on
y
de
l
t
t
pressan
sed
y
w
fsuperior in preventing new depressive episodes but had
f
co
at
(
)
In the subgroup analysis on the prevention of depressive episodes, patients with BD II
benefited significantly with antidepressants (used as combination or monotherapy) at long-
pa
r
I
y
t
A
om
.
an
h
en
t
t
f
g
se
w
seco
i
era
t
ha
r
t
D
no
nd
l
on
ho
i
-
t
B
t
ere
Cochrane RoB.
,
on
t
t
er
m mania/hypomania episodes (RR=2.35, 95% CI 1.42 to 3.91; NNH=4.3)
w
pressants
bu
i
term but not those with BD I. Apart from that, only second-generation antidepressants were
de
t
benefited significantly with antidepressants (used as combination or monotherapy) at long- n
term but not those with BD I. Apart from that, only second-generation antidepressants were
ct
f
can
hree
g
g
f
ha
t
o
C
11
d
f In
e
ba
v
hi
e.
nianalysis
si
h
R
i
i
f
as
nd
k
T
T
eon the prevention of depressive episodes,
f
tsubgroup
r
t
o
s
spatients with BD
ou
o
i
outhe
be
y
b
l
found to be significantly effective. Three out of 11 RCTs had high risk of bias based on
oII
i
f
sed
term but not those with BD I. Apart from that, only second-generation antidepressants were
found to be significantly effective. Three out of 11 RCTs had high risk of bias based on
och
B
.
However, CANMAT states that usage of antidepressants in BD II remains controversial due
e Ro
an
r
Cochrane RoB.
C benefited significantly with antidepressants (used as combination or monotherapy) at long-
found to be significantly effective. Three out of 11 RCTs had high risk of bias based on
40
to safety and effectiveness concerns.
Cochrane RoB.
term but not those with BD I. Apart from that, only second-generation antidepressants were
Cochrane RoB.
found to be significantly effective. Three out of 11 RCTs had high risk of bias based on
However, CANMAT states that usage of antidepressants in BD II remains controversial due However, CANMAT states that usage of antidepressants in BD II remains controversial due
However, CANMAT states that usage of antidepressants in BD II remains controversial due
to safety and effectiveness concerns.
4
0
40
A meta-analysis on SGA LAI on BD, four RCTs found that risperidone LAI compared with oral
to safety and effectiveness concerns.
Cochrane RoB.
However, CANMAT states that usage of antidepressants in BD II remains controversial due
40
to safety and effectiveness concerns.
52, level I
active control (olanzapine, aripiprazole, quetiapine, ziprasidone) had:
40
to safety and effectiveness concerns.
A However, CANMAT states that usage of antidepressants in BD II remains controversial due
A meta-analysis on SGA LAI on BD, four RCTs found that risperidone m
similar relapse rate for overall and manic/hypomanic episodes LAI compared with oral eta-analysis on SGA LAI on BD, four RCTs found that risperidone LAI compared with oral
A meta-analysis on SGA LAI on BD, four RCTs found that risperidone LAI compared with oral
active control (olanzapine, aripiprazole, quetiapine, ziprasidone) had:
z
praz
e,
e,
rd effectiveness concerns.
to safety an
:
ol
prasi
ha
40
z
ap
activ
,
ol
higher relapse rate of depressive episodes (RR=1.83, 95% CI 1.05 to 3.19)
ne
r
2
i
q
a
n
5
)
i
52, level I
i
t
ap
pi
i
e cont
d
an
ne
e
do
i
lev
l I
ue
(
ol
,
A meta-analysis on SGA LAI on BD, four RCTs found that risperidone LAI compared with oral
52, level I
active control (olanzapine, aripiprazole, quetiapine, ziprasidone) had:
i
a
d m
r
an
e
v
c/
sod
ni
i
ap
t
po
or
o
si
ep
a
el
ar
se
hy
eral
r
es
m
an
f
l
i
m
similar relapse rate for overall and manic/hypomanic episodes
c
l
similar all-cause discontinuation rate
active control (olanzapine, aripiprazole, quetiapine, ziprasidone) had: 1.05 t o 3.1 9)
52, level I
similar relapse rate for overall and manic/hypomanic episodes
es (
ep
95
higher relapse rate of depressive episodes (RR=1.83, 95% CI 1.05 to 3.19)
sod
de
R
I
a
r
r
v
i
pressi
g
A meta-analysis on SGA LAI on BD, four RCTs found that risperidone LAI compared with oral
R
=
C
se
ap
he
%
e o
f
r
1.83,
el
e
t
hi
comparable risk of EPS and weight gain but higher risk of hyperprolactinemia (RR=5.75,
higher relapse rate of depressive episodes (RR=1.83, 95% CI 1.05 to 3.19)
active control (olanzapine, aripiprazole, quetiapine, ziprasidone) had:
similar relapse rate for overall and manic/hypomanic episodes 52, level I
a
m
i
scon
t
al
e
si
cau
t
n r
nu
i
se di
95% CI 2.03 to 16.29)
similar all-cause discontinuation rate
l
l
atio
ar
-
higher relapse rate of depressive episodes (RR=1.83, 95% CI 1.05 to 3.19)
similar all-cause discontinuation rate
similar relapse rate for overall and manic/hypomanic episodes
Quality assessment based on the Jadad scores of the RCTs were 3 - 5. ac t i ne m i a ( R R =5 . 75 ,
ht
he
w
S
r
g
ei
P
a
g
nd
r
hi
i
comparable risk of EPS and weight gain but higher risk of hyperprolactinemia (RR=5.75,
k
s
hy
o
prol
o
f
t
g
pe
e
comparabl
r
i
r
n
ai
f
E
s
k
bu
similar all-cause discontinuation rate
higher relapse rate of depressive episodes (RR=1.83, 95% CI 1.05 to 3.19)
comparable risk of EPS and weight gain but higher risk of hyperprolactinemia (RR=5.75,
%
95
I
2.03
.
o 16
95% CI 2.03 to 16.29)
C
29
t
)
comparable risk of EPS and weight gain but higher risk of hyperprolactinemia (RR=5.75,
95% CI 2.03 to 16.29)
CANMAT guidelines recommend that psychosocial strategies should be used to improve
Q l i tsimilar all-cause discontinuation rate r es o f t he R C T s w ere 3 - 5 .
Quality assessment based on the Jadad scores of the RCTs were 3 - 5.
y
sco
ba
ss
ed
t
he
s
t
on
ua
asse
en
m
Jad
ad
95% CI 2.03 to 16.29)
Quality assessment based on the Jadad scores of the RCTs were 3 - 5.
treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should
comparable risk of EPS and weight gain but higher risk of hyperprolactinemia (RR=5.75,
Quality assessment based on the Jadad scores of the RCTs were 3 - 5. 40
CANMAT guidelines recommend that psychosocial strategies should be used to guidelines recommend that psychosocial strategies should be used to improve
C
95% CI 2.03 to 16.29)
be offered. They are effective in preventing relapse of any mood episode and mania. improve ANMAT
CANMAT guidelines recommend that psychosocial strategies should be used to improve
Quality assessment based on the Jadad scores of the RCTs were 3 - 5.
treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should
CANMAT guidelines recommend that psychosocial strategies should be used to improve
treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should
In a systematic review on BD, clozapine:
53, level I
0
40
4
be offered. They are effective in preventing relapse of any mood episode and mania.
be offered. They are effective in preventing relapse of any mood episode and mania.
treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should
40
was as effective as other APs (chlorpromazine, risperidone, olanzapine and quetiapine)
be offered. They are effective in preventing relapse of any mood episode and mania. improve
CANMAT guidelines recommend that psychosocial strategies should be used to
be offered. They are effective in preventing relapse of any mood episode and mania.
40
53, level I
5
In a systematic review on BD, clozapine:n a systematic review on BD, clozapine:
lev
,
l
e
in the improvement of Bech-Rafaelsen Mania Scale (BRMS) or YMRS scores
3
I
I treatment adherence. If ineffective, LAI medications e.g. risperidone or aripiprazole LAI should
In a systematic review on BD, clozapine: orp r omaz i ne , r i s pe r i do ne , ol an z ap i ne an d q ue 40 t i ap i ne )
53, level I
s
as
eff
as
w
(
chl
P
ectiv
r
had common AEs of sedation, constipation and tachycardia whilst severe AEs were
was as effective as other APs (chlorpromazine, risperidone, olanzapine and quetiapine)
be o
othe
e
as
A
ffered. They are effective in preventing relapse of any mood episode and mania.
In a systematic review on BD, clozapine: 53, level I
was as effective as other APs (chlorpromazine, risperidone, olanzapine and quetiapine)
i
in the improvement of Bech-Rafaelsen Mania Scale (
reduced white blood cells (5.3%) and seizures (2%) BRMS) or YMRS scores n the improvement of Bech-Rafaelsen Mania Scale (BRMS) or YMRS scores
was as effective as other APs (chlorpromazine, risperidone, olanzapine and quetiapine)
in the improvement of Bech-Rafaelsen Mania Scale (BRMS) or YMRS scores
In a systematic review on BD, clozapine: 53, level I t i on an d t ach y cardi a w hi l st sev e r e A E s w ere
on
s
E
i
f
d
con
o
ha
co
had common AEs of sedation, constipation and tachycardia whilst severe AEs were
m
st
da
when used as add-on treatment for treatment-resistant BD, was superior than the
m
i
A
,
on
pa
se
t
in the improvement of Bech-Rafaelsen Mania Scale (BRMS) or YMRS scores
had common AEs of sedation, constipation and tachycardia whilst severe AEs were
treatment as usual (lithium, valproate or APs) in all outcome measures (BPRS, CGI and
r was as effective as other APs (chlorpromazine, risperidone, olanzapine and quetiapine)
ures
d
)
sei
an
z
s
reduced white blood cells (5.3%) and seizures (2%)
d w
l
(
5
2
(
d cel
oo
hi
%)
e bl
t
3%
.
ed
uce
had common AEs of sedation, constipation and tachycardia whilst severe AEs were
reduced white blood cells (5.3%) and seizures (2%)
in the improvement of Bech-Rafaelsen Mania Scale (BRMS) or YMRS scores
BRMS) except for the HAM-D
h
as
t
as
t
t
eri
an
sup
ad
r
,
o
w
w
use
a
n
o
B
he
f
d
D
r
t
-
r
e
t
n
n
r
e
h
m
e
r
n
a
t
e
t
a
-
o
e
when used as add-on treatment for treatment-resistant BD, was superior than the
t
t
d
st
m
n
esi
reduced white blood cells (5.3%) and seizures (2%)
treatment as usual (lithium, valproate or APs) in all outcome measures (BPRS, CGI and
,
t had common AEs of sedation, constipation and
d
when used as add-on treatment for treatment-resistant BD, was superior than the
P
an
R
C
Gwere
A
I
S
r
B
ou
l
i
t
s
co
)
t
(
hi
al
v
n
i
ltachycardia whilst severe AEs
um,
al
al
sure
ea
t
en
m
r
o
proat
s
(
ea
e
P
m
usu
t
e
m
as
when used as add-on treatment for treatment-resistant BD, was superior than the
treatment as usual (lithium, valproate or APs) in all outcome measures (BPRS, CGI and
)
r
R
o
cep
ex
B reduced white blood cells (5.3%) and seizures (2%)
BRMS) except for the HAM-D
M
he
t
-
S
D
H
f
M
t
A
General principles of maintenance pharmacotherapy in BD are as follows: 50
treatment as usual (lithium, valproate or APs) in all outcome measures (BPRS, CGI and
BRMS) except for the HAM-D
when used as add-on treatment for treatment-resistant BD, was superior than the
BRMS) except for the HAM-D
o medications effective and safe in acute episodes should be continued
treatment as usual (lithium, valproate or APs) in all outcome measures (BPRS, CGI and
o monotherapy should be preferred
General principles of maintenance pharmacotherapy in BD are as follows: General principles of maintenance pharmacotherapy in BD are as follows: 5 50 0
BRMS) except for the HAM-D
50
o for combination therapy, pharmacological agents with different mechanisms of action
ct
es
sod
sho
v
ed
i
e
nu
f
o medications effective and safe in acute episodes should be continued
t
f
d be
t
con
f
ul
d sa
e
m
i
ed
e epi
i
e an
n acu
catio
i
ns e
o
General principles of maintenance pharmacotherapy in BD are as follows: 50
General principles of maintenance pharmacotherapy in BD are as follows:
o medications effective and safe in acute episodes should be continued
on
f
should be used and, benefits and risks should be re-evaluated every six months or
pre
m
r
othe
y
ed
o monotherapy should be preferred
ap
r
d be
e
r
ul
sho
o
earlier if indicated
y
t
on
i
he
ap
r
combi
na
t
or
o medications effective and safe in acute episodes should be continued 50
aco
o for combination therapy, pharmacological agents with different mechanisms of action
o monotherapy should be preferred l o g i cal a g en t s w i t h di f f e r en t m ech an i s m s o f a ct i on
arm
,
ph
f
o General principles of maintenance pharmacotherapy in BD are as follows:
o monotherapy should be preferred
d
ctive and safe in acute episodes should be continued
d
an
an
r
ul
e
t
o medications effe
ed
m
o
k
hs
s
u
al
sed
i
-
r
sho
on
t
ua
ev
be
s
,
f
d
ery
t
i
e
ev
be
sho
should be used and, benefits and risks should be re-evaluated every six months or
ne
b
d
s
x
si
ul
o for combination therapy, pharmacological agents with different mechanisms of action r
o for combination therapy, pharmacological agents with different mechanisms of action
should be used and, benefits and risks should be re-evaluated every six months or
er
d
cate
earlier if indicated
l
i
nd
i
i
i
a
f
o
e monotherapy should be preferred
r
should be used and, benefits and risks should be re-evaluated every six months or
earlier if indicated
Recommendation 5
o for combination therapy, pharmacological agents with different mechanisms of action
earlier if indicated
should be used and, benefits and risks should be re-evaluated every six months or
For maintenance pharmacotherapy of bipolar disorder (BD),
Recommendation 5 Recommendation 5
earlier if indicated
○ lithium and quetiapine are the preferred first-line monotherapy while lithium plus
r
quetiapine or aripiprazole are the preferred first-line combination therapy
ntenan
ai
m
For maintenance pharmacotherapy of bipolar disorder (BD),
Fo
aco
t
l
B
ar
ce
he
Recommendation 5 ph t i ar m i ne are r ap y o p f r e bi f e po r ed di i r s st order ( m D ) , othe r ap y w hi l e l i t hi um pl us
Recommendation 5
For maintenance pharmacotherapy of bipolar disorder (BD),
○ antidepressant monotherapy should be avoided
○
○ lithium and quetiapine are the preferred first-line monotherapy while lithium plus
f
t
um
ap
l
i
-
l
ne
hi
t
i
he
ue
d
r
an
on
q
For maintenance pharmacotherapy of bipolar disorder (BD), na t i on t he r ap y
○ lithium and quetiapine are the preferred first-line monotherapy while lithium plus
Recommend
iation 5
○ aripiprazole or risperidone long-acting injectables may be considered in patients who
i
ue
q
er
ne
pre
ed
e ar
t
-
l
a
t
ol
he
or
i
e
f
r
f
combi
i
r
pi
ap
i
r
praz
ne
quetiapine or aripiprazole are the preferred first-line combination therapy
s
t
have poor adherence to oral medications especially in preventing manic episodes
quetiapine or aripiprazole are the preferred first-line combination therapy
ul
r
de
ap
oi
y
sho
a
○ antidepressant monotherapy should be avoided
othe
○ For maintenance pharmacotherapy of bipolar disorder (BD),
t
ntid
essa
av
r
m
on
○ lithium and quetiapine are the preferred first-line monotherapy while lithium plus
ep
n
d be
d
quetiapine or aripiprazole are the preferred first-line combination therapy
t
actin
i
en
i
w
ectabl
g
ho
○ aripiprazole or risperidone long-acting injectables may be considered in patients who
○ ○ lithium and quetiapine are
n
t
j
-
ng
do
i
e lothe preferred first-line monotherapy
arip
i
r
n
praz
es
spe
ed
i
r
n pa
i
e or
ol
○ antidepressant monotherapy should be avoided m ay be con si de rwhile lithium s plus
○ antidepressant monotherapy should be avoided
○ aripiprazole or risperidone long-acting injectables may be considered in patients who
t
t
l
y
l
e poor
i
en
on
ev
ad
he
n pr
en
s
r
i
es
i
have poor adherence to oral medications especially in preventing manic episodes
m
esp
ed
c
eci
i
e
ha
pi
an
o
ce
a
ng
ca
t
i
oral
sod
m
que
vtiapine or aripiprazole are the preferred first-line combination therapy
○ aripiprazole or risperidone long-acting injectables may be considered in patients who
have poor adherence to oral medications especially in preventing manic episodes
○ antidepressant monotherapy should be avoided
have poor adherence to oral medications especially in preventing manic episodes
○ aripiprazole or risperidone long-acting injectables may be considered in patients who
have poor adherence to oral medications especially in preventing manic episodes
15
1
5
15
15
15
15
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