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Chapter 58. Bipolar Disorders

Patient LC requires treatment for bipolar disorder and is currently in a depressive episode. The patient has a history of predominantly depressive episodes in the past 3 years. The patient refuses to take more than one medication at a time for management of symptoms and relapse prevention. Which medication will you recommend for LC, confident that it can be used as monotherapy for managing the associated symptoms? Select all that apply.

a. Lithium

b. Lamotrigine

c. Olanzapine

d. Quetiapine

e. Citalopram

Answer a is correct. Lithium is the classic mood stabilizer often used alone to manage both phases of bipolar disorder: manic/hypomanic as well as depressive.

Answer b is correct. Lamotrigine is FDA-approved for bipolar disorder I and is often used as an alternative to lithium for bipolar depressive episodes and may be used monotherapy if warranted.

Answer c is incorrect. Olanzapine is an atypical antipsychotic agent that is FDA-approved for the treatment of acute mania as well as maintenance treatment in bipolar disorder; however, it is not approved for managing bipolar depression monotherapy. Only when combined in the olanzapine-fluoxetine combination (OFC; trade name Symbyax; fluoxetine is an selective serotonin reuptake inhibitor [SSRI] antidepressant) it is approved for use in bipolar depression.

Answer d is correct. Quetiapine is FDA-approved as monotherapy for managing bipolar depression.

Answer e. is incorrect. Citalopram is an SSRI that may be used in conjunction with a mood stabilizer (lithium, divalproex sodium, or an atypical antipsychotic agent) for the bipolar depressive episode if lithium or lamotrigine is not used. An antidepressant should never be used as monotherapy, even in the depressive phase of bipolar disorder. It must always be used in conjunction with a mood stabilizing agent to prevent manic episodes (ie, antidepressant-induced manic switch).

You are the pharmacist on a Pharmacy and Therapeutic committee at your hospital. The committee has asked you to present on alternatives to lithium and lamotrigine for managing bipolar depression in patients with bipolar disorder. Which of the following agents will you present data on, based on their FDA-approved indication for this therapeutic use? Select all that apply.

a. Asenapine

b. Iloperidone

c. Lurasidone

d. Paliperidone

e. Quetiapine

Answer c is correct. Lurasidone (Latuda) is an atypical antipsychotic that is FDA-approved for bipolar depression. Starting dose is 20 mg/d, and the dosing range for bipolar disorder is ...

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