Bipolar Disorder Drugs

IR: 300mg TID
ER: 450mg BID

Acute mania: 0.8-1.2 mEq/L
Maintenance: 0.6-1.0 mEq/L

None (renally excreted)

Mania: 6-10 days (full resolution may take up to 3 weeks)
Depression: ~ 1 month for maximal improvement

Boxed warning: Lithium toxicity
Decreased renal ability to concentrate urine, nephrogenic diabetes insipidus (NDI)
Caution in patients with significant fluid loss
Avoid medications that significantly alter lithium concentration
Increased risk of fetal malformations, cardiac abnormalities (Ebstein’s anomaly)

Discontinue lithium if possible
If need to continue may consider amiloride

Fine hand tremor, polyuria, mild thirst

1.5-2.0 mEq/L
Diarrhea, vomiting, drowsiness, muscle weakness, decreased coordination

2.0-2.5 mEq/L
Ataxia, blurred vision, tinnitus, EKG changes (t-wave flattening, heart block, arrhythmias)

>3.0mEq/L
Neurological changes, coma

Hemodialysis is effective in removing lithium
Significant decrease in concentration after one session however may have rebound effect

Recommended when:
• Level > 4.0 mEq/L
• Level > 2.5 mEq/L with serious cardiac/neurologic symptoms

NSAIDs
ACEIs/ARBs
Thiazide diuretics
Loop diuretics
Reduced sodium intake

Theophylline
Verapamil
Osmotic diuretics
caffeine
Sodium, sodium bicarbonate antacids

Category D, fetal risk occurs, ebstein's anomaly

Loading:
IR: 30 mg/kg x 2 days or, ER: 25mg/kg x 2 days THEN IR: 20mg/kg ER: 25 mg/kg

Titration: 500 or 750 mg qhs

50-125 mcg/mL (>70-90 mcg/mL preferred)

CYP2C19, Glucuronidation, oxidation

VPA increases the level of lamotrigine, warfarin
VPA levels are decreased by carbapenems, ritonavir

Boxed warnings:
Hepatic failure
Pancreatitis
Teratogenic effects, neural tube defects and decreased IQ

Dose-related thrombocytopenia
Hyperammonemia/encephalopathy
Hypothermia
DRESS

Pregnancy category D, neural tube defects

25mg daily

delayed due to slow titration

Boxed warning: Life-threatening rash (SJS, TEN)
DRESS
Others: Blood dyscrasias, aseptic meningitis

None

Estrogen containing products increase lamotrigine levels by up to 50%
VPA increases levels of lamotrigine

Class C drug, can cause neural tube defects but at a lower rate than VPA

200mg BID

Induces CYP3A4 and CYP1A2

Boxed warnings:
Fatal hypersensitivity reactions: DRESS, SJS, TEN (25-30% risk of also having reaction to oxcarbazepine)
Anemia and agranulocytosis

Avoid in patients with history of hepatic
porphyria
Increased risk of suicidality
Teratogenicity
Potential for withdrawal seizures after abrupt discontinuation
Hyponatremia

Patients of asian decent must have testing done for the presence of HLA-B*1502, found almost exclusively in this population and has a 10x risk of developing SJS/TENS

~7 days in mania