Page 44 - e-book CPG - Bipolar Disorder
P. 44
CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)
-
7
y
0
al
1
ere
-
p
d
an
e
1
s
w
13
o
an
d
t
-
y
were consistent in a subgroup analysis of 10 - 12-year-old and 13 - 17-year-old study
st
si
f
n
g
ud
r
st
a
r
y
-
y
a
e
con
si
2
ou
o
r
-
i
l
a
en
d
l
sub
1
-
o
were consistent in a subgroup analysis of 10 - 12-year-old and 13 - 17-year-old study
were consistent in a subgroup analysis of 10 - 12-year-old and 13 - 17-year-old study
en
h or
subjects with or without prior bipolar treatment
sub
m
ho
t
ar
j
l
i
t
prio
w
r
w
po
bi
i
s
ea
t
ut
ec
t
r
t
subjects with or without prior bipolar treatment t
subjects with or without prior bipolar treatment
(
01
esp
s
w
e r
p<0.
a
do
t
h bot
sho
h
on
ses
ed
er
t
r
i
es w
)
t
showed greater response rates with both doses (p<0.01)
ea
g
r
showed greater response rates with both doses (p<0.01)
showed greater response rates with both doses (p<0.01)
ce,
da
r
somnol
ed
E
d EP
h
on
w
h
The commonly reported AEs were somnolence, headache and EPS.
ere
t
S
l
com
T
ea
m
s
en
y
e
or
A
an
ep
che
The commonly reported AEs were somnolence, headache and EPS. .
The commonly reported AEs were somnolence, headache and EPS.
In a recent RCT on 10 - 17-year-old patients with BD I in manic/mixed episodes, ziprasidone
t
i
prasi
x
i
I
i
nt
i
sod
o
n
s
ep
T
l
t
e
i
on
e
r
w
-
es
d
do
n
y
-
c/
I
i
a
1
a
m
-
R
i
n
7
m
ece
10
a
t
d
a
h
,
C
n
D
r
e
ne
p
z
B
In a recent RCT on 10 - 17-year-old patients with BD I in manic/mixed episodes, ziprasidone
In a recent RCT on 10 - 17-year-old patients with BD I in manic/mixed episodes, ziprasidone
-
f
bo
T
t
e
he
(
)
1.32
M
.
n
D
f
al
m
,
t
t
o
was more effective than placebo (MD in YMRS total score= -4.23, 95% CI -7.14 to -1.32). The
w
sco
-
r
e=
pl
t
e
ha
ace
4.23
as
ore
7.14
n
-
Y
o
i
i
t
95
S
%
ec
I
M
v
R
C
was more effective than placebo (MD in YMRS total score= -4.23, 95% CI -7.14 to -1.32). The
was more effective than placebo (MD in YMRS total score= -4.23, 95% CI -7.14 to -1.32). The
e
v
l
common AEs were somnolence, fatigue and nausea.
e
l
2
125, level I
1
5
,
common AEs were somnolence, fatigue and nausea. 125, level I
common AEs were somnolence, fatigue and nausea. 125, level I I
common AEs were somnolence, fatigue and nausea.
C
o
R
T
m
/
c
e
x
i
i
h
t
i
n
a
m
d
ed
w
S
N
sho
pi
e
es
sod
e
y
-
-
r
a
7
10
n
1
-
ol
D
B
w
I
w
ds
h
t
i
ed
o
i
d
nd
A
bl
-
le
A double-blinded RCT on 10 - 17-year-olds with BD I with manic/mixed episodes showed NS
u
b
A double-blinded RCT on 10 - 17-year-old with BD I with manic/mixed episodes showed NS
A double-blinded RCT on 10 - 17-year-olds with BD I with manic/mixed episodes showed NS
,
di f f erence i n e f f ec t i v en ess an d sa f ety be t w ee n v al proat e E R m on o t he r ap y an d pl ace bo . 1 126, level l
e
6
difference in effectiveness and safety between valproate ER monotherapy and placebo.
2
lev
difference in effectiveness and safety between valproate ER monotherapy and placebo.
126,
difference in effectiveness and safety between valproate ER monotherapy and placebo.
126, level
I I
I level I
-
ne
on
t
y
y
si
eta
bo
i
A meta-analysis of three RCTs on quetiapine monotherapy vs placebo in children and
i
m
n
pl
h
r
r
s
an
dren
T
e
m
ap
l
d
al
R
C
e
ace
on
chi
of
A
s
othe
q
i
ue
s
v
an
t
ap
A meta-analysis of three RCTs on quetiapine monotherapy vs placebo in children and
A meta-analysis of three RCTs on quetiapine monotherapy vs placebo in children and
2
,
e
lev
1
7
adolescents with bipolar depression showed NS difference in the following outcomes: 127, level I I
l
adolescents with bipolar depression showed NS difference in the following outcomes:
adolescents with bipolar depression showed NS difference in the following outcomes: 127, level I
127, level I
adolescents with bipolar depression showed NS difference in the following outcomes:
G
sco
C
ng
e
)
-
t
s
a
r
es
hi
,
i
S
r
-
po
es
S
D
scal
Children’s depression rating scale revised (CDRS-R), CGI-BP-S scores, response and
C
R
R
i
on
ev
nse
an
,
sed
r
C
l
P
d
B
-
r
I
de
dren’
pressi
(
Children’s depression rating scale revised (CDRS-R), CGI-BP-S scores, response and
Children’s depression rating scale revised (CDRS-R), CGI-BP-S scores, response and
r remission rates
emissi
ates
on
r
remission rates
remission rates
e
nu
du
e
t
scon
a
i
o AE
t
t
atio
n r
discontinuation rate due to AEs
di
s
discontinuation rate due to AEs
discontinuation rate due to AEs
B ase d on t he G R A D E as sessmen t , al l ou t co m e q ua l i t i es w ere m od era t e t o hi g h .
Based on the GRADE assessment, all outcome qualities were moderate to high.
Based on the GRADE assessment, all outcome qualities were moderate to high.
Based on the GRADE assessment, all outcome qualities were moderate to high.
s
1
s
t
d
i
o
h
8
-
n
t
a
si
0
ol
e
1
y
r
N
-
ou
A
-
h
n
y
po
bi
on
M
,
w
of
son
C
e
r
ng
l
ar
Ts
an
ou
I In an NMA of four RCTs on 10 - 18-year-old young persons with bipolar depression, the
pe
f
pre
de
R
r
In an NMA of four RCTs on 10 - 18-year-old young persons with bipolar depression, the
In an NMA of four RCTs on 10 - 18-year-old young persons with bipolar depression, the
)
ne
compa
i
P
i
f
i
t
sa
A
l
i
f
t
f
r
s
d
v
ere
en
an
f
o
ue
w
e
h
effectiveness and safety of AAPs (lurasidone, OFC and quetiapine) were compared with
ne
,
ec
(
ap
e
O
do
t
FC
d
ess
A
t
w
asi
ur
an
ed
q
y
effectiveness and safety of AAPs (lurasidone, OFC and quetiapine) were compared with
effectiveness and safety of AAPs (lurasidone, OFC and quetiapine) were compared with
,
8
128, level I
lev
e
placebo. The findings were: 1 128, level I l I
2
placebo. The findings were: 128, level I
placebo. The findings were:
placebo. The findings were:
improvement in CDRS-R with lurasidone (MD = -5.70, 95% CI -8.66 to -2.76) and OFC OFC
improvement in CDRS-R with lurasidone (MD = -5.70, 95% CI -8.66 to -2.76) and
improvement in CDRS-R with lurasidone (MD = -5.70, 95% CI -8.66 to -2.76) and OFC
improvement in CDRS-R with lurasidone (MD = -5.70, 95% CI -8.66 to -2.76) and OFC
8
t
%
n
pi
1
t
-
u
i
t
(MD= - 5.0, 95% CI -8.63 to -1.38) but not with quetiapine
(
q
D
u
o
3
8.63
.
5.0
=
b
etia
o
-
h
-
I
t
C
ne
w
95
,
M
)
(MD= - 5.0, 95% CI -8.63 to -1.38) but not with quetiapine
(MD= - 5.0, 95% CI -8.63 to -1.38) but not with quetiapine
urasi
M
t
(
i
,
0.68
%
C
n
i
ne
r
l
S
G
P
D
w
40
.
es
0
-
=
I
95
B
-
h
prov
-
-
I
i
pressi
improvement in CGI-BP-S depression scores with lurasidone (MD= -0.40, 95% CI -0.68
sco
on
de
do
m
C
ement
improvement in CGI-BP-S depression scores with lurasidone (MD= -0.40, 95% CI -0.68
improvement in CGI-BP-S depression scores with lurasidone (MD= -0.40, 95% CI -0.68
o
n
t
C
w
-
0.12
h
b
F
i
t
to -0.12) but not with OFC
O
o
)
t
t
u
to -0.12) but not with OFC
to -0.12) but not with OFC
-
0.68
m
M
scores
(
l
do
I
i
prov
ne
l
C
-
0.40,
h
P
I
t
t
G
S
w
-
i
D
o
eral
i
%
improvement in CGI-BP-S overall scores with lurasidone (MD= -0.40, 95% CI -0.68 to
-
n
95
ov
ement
B
C
urasi
=
improvement in CGI-BP-S overall scores with lurasidone (MD= -0.40, 95% CI -0.68 to
improvement in CGI-BP-S overall scores with lurasidone (MD= -0.40, 95% CI -0.68 to
-
ne
-0.12) but not with OFC and quetiapine
i
t
FC
)
d
h
o
t
0.12
i
w
O
q
ap
t
ue
t
an
n
bu
i
-0.12) but not with OFC and quetiapine
-0.12) but not with OFC and quetiapine
w
(
N
esp
s
r
ne
;
I
e
T=5
64
67
ate
C
do
prov
.
1
N
on
i
m
h
o 4.
i
)
l
urasi
95
improvement in response rate with lurasidone (OR=2.64, 95% CI 1.67 to 4.01; NNT=5)
=2.
R
01
n
r
i
ement
O
t
,
t
%
improvement in response rate with lurasidone (OR=2.64, 95% CI 1.67 to 4.01; NNT=5)
improvement in response rate with lurasidone (OR=2.64, 95% CI 1.67 to 4.01; NNT=5)
O
(
i
.
%
)
=
u
ap
FC
,
i
64
=2
n
T
t
b
N
t
95
6
e
R
t
w
o
d O
o 4
an
i
n
q
1.43
I
t
h
t
;
ue
C
.
and OFC (OR=2.64, 95% CI 1.43 to 4.50; NNT=6) but not with quetiapine
N
50
and OFC (OR=2.64, 95% CI 1.43 to 4.50; NNT=6) but not with quetiapine
and OFC (OR=2.64, 95% CI 1.43 to 4.50; NNT=6) but not with quetiapine
FC
1
i
7
t
7
T
e
emissi
=1.
w
I
b
1
ement
m
.
n
t
;
=
r
,
i
N
(
N
o
prov
t
r
0
improvement in remission rate with OFC (OR=1.93, 95% CI 1.10 to 3.17; NNT=7) but
)
O
n
O
o
h
%
i
a
u
C
1
t
.
93
95
R
3
improvement in remission rate with OFC (OR=1.93, 95% CI 1.10 to 3.17; NNT=7) but
improvement in remission rate with OFC (OR=1.93, 95% CI 1.10 to 3.17; NNT=7) but
n
not with lurasidone and quetiapine
urasi
l
an
d
h
t
i
w
qu
etia
t
o
ne
ne
pi
do
not with lurasidone and quetiapine
not with lurasidone and quetiapine
ace
v
atio
i
O
nu
scon
R
(
=0
t
s
bo
n
pl
32
atio
t
n due
t
i
er
q
,
ue
scon
i
nu
di
ne
d
ha
.
ew
ap
i
f
E
A
di
t
discontinuation due to AEs, quetiapine had fewer discontinuation vs placebo (OR=0.32, ,
o
s
discontinuation due to AEs, quetiapine had fewer discontinuation vs placebo (OR=0.32,
discontinuation due to AEs, quetiapine had fewer discontinuation vs placebo (OR=0.32,
95% CI 0.07 to 0.83) whereas OFC had more discontinuation vs placebo (OR=3.31,
.
ace
r
FC
atio
95
d
nu
i
pl
bo
ha
%
(
)
31
s
s
O
n
0
ea
w
o
83
he
O
.
C
I
t
v
R
t
m
o
r
=3
scon
.
di
07
0
e
95% CI 0.07 to 0.83) whereas OFC had more discontinuation vs placebo (OR=3.31, ,
95% CI 0.07 to 0.83) whereas OFC had more discontinuation vs placebo (OR=3.31,
95% CI 1.08 to 8.75) and quetiapine (OR=15.08, 95% CI 2.32 to 56.84)
95% CI 1.08 to 8.75) and quetiapine (OR=15.08, 95% CI 2.32 to 56.84)
95% CI 1.08 to 8.75) and quetiapine (OR=15.08, 95% CI 2.32 to 56.84)
95% CI 1.08 to 8.75) and quetiapine (OR=15.08, 95% CI 2.32 to 56.84)
O
ed
R
,
A
ne
ha
S
an
g
he
k
g
an
n
ue
s
by
d
l
ap
FC
U
urasi
i
k
i
t
ol
i
do
hi
d
l
r
ne
an
C
d on
ow
t
f
ase
Based on SUCRA rankings, lurasidone had the highest rank followed by OFC and quetiapine
he
r
s
B
t
q
Based on SUCRA rankings, lurasidone had the highest rank followed by OFC and quetiapine
Based on SUCRA rankings, lurasidone had the highest rank followed by OFC and quetiapine
l
f
l
er
f
f
ol
as
t
i in terms of effectiveness. For safety, quetiapine was ranked first followed by lurasidone, ,
ec
by
f
f
i
i
ed
r
an
do
k
ed
q
r
i
sa
ap
o
e
,
n
y
Fo
urasi
t
m
t
v
s
w
en
f
ue
r
e
ow
t
ess.
ne
t
ne
i
s
in terms of effectiveness. For safety, quetiapine was ranked first followed by lurasidone,
in terms of effectiveness. For safety, quetiapine was ranked first followed by lurasidone,
pl ace bo an d O FC . G R A D E asse ssm en t g av e m i x ed q ua l i t y on t he v ario us out co m es .
placebo and OFC. GRADE assessment gave mixed quality on the various outcomes.
placebo and OFC. GRADE assessment gave mixed quality on the various outcomes.
placebo and OFC. GRADE assessment gave mixed quality on the various outcomes.
R ec ommend at i on 1 1
Recommendation 11
Recommendation 11
Recommendation 11
esc
h bi
d adol
an
i
t
r
di
For children and adolescents with bipolar disorder: :
ar
po
sorde
l
r
s
dren
chi
en
l
t
w
Fo
For children and adolescents with bipolar disorder:
For children and adolescents with bipolar disorder:
i
ed
sod
i
cho
ep
cal
t
psy
an
o atypical antipsychotics* monotherapy may be used in manic or mixed episodes
on
or
m
es
u
ay
n m
be
othe
i
c
m
pi
s
i
i
an
ed
ap
x
t
cs
m
i
aty
*
y
r
o atypical antipsychotics* monotherapy may be used in manic or mixed episodes
o
o atypical antipsychotics* monotherapy may be used in manic or mixed episodes
d
on
e
t
ay
i
ne
na
m
combi
ssi
ep
o lurasidone and olanzapine/fluoxetine combination may be used in depressive
n
be
use
d
f
do
ap
d
ne
i
/
r
urasi
i
e
v
etin
an
x
uo
l
ol
z
an
l
e
o lurasidone and olanzapine/fluoxetine combination may be used in depressive
o
o lurasidone and olanzapine/fluoxetine combination may be used in depressive
sod
i
s
ep
e
episodes
episodes
episodes
do
ne
ol
r
spe
i
ne
ne
,
do
r
e,
do
i
,
arip
urasi
l
,
praz
i
an
a
pi
ne
z
i
,
i
ap
t
ol
q
ue
ne
prasi
z
i
ne
pi
nd
*aripiprazole, asenapine, lurasidone, olanzapine, quetiapine, risperidone and ziprasidone
na
ase
a
*
*aripiprazole, asenapine, lurasidone, olanzapine, quetiapine, risperidone and ziprasidone
*aripiprazole, asenapine, lurasidone, olanzapine, quetiapine, risperidone and ziprasidone
R ef e r t o A pp en dix 1 1 f o r S ug ge sted P a e dia t r i c M ed i ca t i on s D os i ng .
Refer to Appendix 11 for Suggested Paediatric Medications Dosing.
Refer to Appendix 11 for Suggested Paediatric Medications Dosing.
Refer to Appendix 11 for Suggested Paediatric Medications Dosing.
8.4. People with Substance Use Disorder
8.4. P eo ple w i t h S ub s t an ce U se D i so rder
8.4. People with Substance Use Disorder
8.4. People with Substance Use Disorder
Substance use disorder (SUD) is a common co-morbidity of BD. Substance use may cause,
S ub st an ce use di sorder ( S U D ) i s a co m m on co - m orbi di t y o f B D . S ub st a nce use m ay cau se,
Substance use disorder (SUD) is a common co-morbidity of BD. Substance use may cause,
Substance use disorder (SUD) is a common co-morbidity of BD. Substance use may cause,
he
or
h
m
al
t
e
i
i
cate
de
r
m
pl
al
t
al
co
un
m
en
l
m
ev
mimic, underlie or complicate mental health disorders. Empirical evidence to guide optimal
op
r
pi
cal
i
o
t
ui
g
de
de
i
nce
i
t
r
de
di
i
c,
sor
E
m
i
m
s.
mimic, underlie or complicate mental health disorders. Empirical evidence to guide optimal
mimic, underlie or complicate mental health disorders. Empirical evidence to guide optimal
30
3
0
30
30
30
