A pilot study of loading versus titration of valproate in the treatment of acute mania

Oral loading of sodium valproate compared to intravenous loading and oral maintenance in acutely manic bipolar patients

BACKGROUND

In patients suffering from bipolar disorders (BPD), we explored to what extent oral loading of sodium valproate (SV) leads to more rapid symptom improvement compared to intravenous loading and oral maintenance administration.

METHODS

Ninety patients (mean age: 35.00 years) with BPD and currently in an acute manic state were randomly assigned to one of three study conditions: oral loading (20 mg/kg oral single-dose SV on the first day, then 10-15 mg/kg SV daily, divided dose), intravenous loading (20 mg/kg SV intravenous injection on the first day, then 10-15 mg/kg orally, divided dose), or oral maintenance administration (15-20 mg/kg SV daily from the beginning) over the first 7 days of treatment. SV plasma levels, side effects and symptoms were evaluated at baseline and on days 1, 3, and 7 after commencing treatment.

RESULTS

There were significant Time-by-Group interactions for symptom improvements, symptom severity, and SV plasma levels, with positive values in the oral and intravenous loading conditions, compared to the oral maintenance condition. Post hoc analyses showed that oral and intravenous conditions led to similar improvements.

CONCLUSIONS

Both oral and intravenous loading of SV led to quicker and more efficient improvement and SV plasma levels as compared to an oral maintenance regimen.

Divalproex sodium in the treatment of adults with bipolar disorder

Divalproex sodium (Depakote, Abbott Laboratories) is an anticonvulsant with well-established efficacy in the treatment of bipolar I disorder, manic or mixed episode. Over the past 10 years, an increased number of studies indicate that divalproex has a broad spectrum of activity in the treatment of bipolar depression and rapid cycling, psychotic symptoms, impulsive aggression and post-traumatic stress disorder. Newer formulations of divalproex, namely the extended-release formulation, are now available. The improved tolerability and convenience of the once-daily extended-release formulation has a significant potential to improve patient compliance and thus, clinical and functional outcomes. The use of divalproex in the treatment of bipolar and other related psychiatric disorders is reviewed.

The management of individuals with bipolar disorder: a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.

Safety, tolerability and efficacy of a rapid dose escalation of quetiapine in bipolar I mania: the FATIMA study

OBJECTIVE

The FATIMA study (FAst TItration of quetiapine fumarate in bipolar I MAnia) evaluated the safety, tolerability and efficacy of a rapid dose escalation of quetiapine in acutely ill bipolar I patients experiencing a manic episode.

METHODS

In an open-label, phase II pilot study, 29 patients aged 18 years or older, hospitalised with a bipolar I manic episode, received quetiapine twice daily for 21 days. Quetiapine was administered at 200, 400, 600, then 800 mg/day on the first 4 days, with flexible dosing (400-800 mg/day) subsequently. The primary endpoint was the proportion of patient dropouts because of adverse drug reactions during the first 7 days. Secondary safety assessments included incidences of adverse drug reactions and significant changes in vital signs. Efficacy assessments included Young Mania Rating Scale (YMRS) and Clinical Global Impressions Severity of Illness (CGI-S) score changes from day 1 to day 21.

RESULTS

Twenty patients (69%) completed the study. No patients withdrew as a result of drug-related adverse events (AEs) during the first 7 days. Twenty-three patients reported 58 adverse events, and most of the adverse events were mild or moderate. No clinically relevant abnormalities in vital signs were reported. Mean YMRS and CGI-S scores decreased significantly from baseline to day 21 (p < 0.001). Response and remission rates were 78 and 70%, respectively, at the end of the study.

CONCLUSION

Rapid dose escalation of quetiapine to 800 mg/day over 4 days was well tolerated and effective in reducing symptoms within 5 days in acutely ill bipolar I patients with a manic episode.

Mood stabilizer loading versus titration in acute mania: audit of clinical practice

OBJECTIVE

The aim of the present study was to investigate whether the use of a loading strategy with lithium or valproate followed recommended practice and second, whether this had any impact on indicators of outcome in acutely manic inpatients.

METHOD

A 12 month retrospective review of admissions to two adult psychiatric units in Auckland, New Zealand, was conducted. Demographic, legal status, psychiatric admissions, outcome indicators (length of stay, intensive care and seclusion use) and medication data were collected for all patients with a diagnosis of acute bipolar mania who started mood stabilizer treatment within 3 days of admission (n=93). Serum levels and adverse effects were also recorded.

RESULTS

In 46.2% of admissions a loading strategy was prescribed, and lithium was the treatment choice in two-thirds of admissions. Serum levels were taken inconsistently, particularly for valproate. No difference was found between loading and titrating for the assessed outcomes in routine practice; average length of stay was 30.2 days; most patients (71.0%) spent time in intensive care (average 8.4 days) and 33.3% spent time in seclusion. More adverse effects occurred with loading (51.2%) compared to titrating (36.0%), particularly with lithium.

CONCLUSION

The literature supports a strong link between rapidly attained high serum levels and positive outcomes. The present study found inconsistent and infrequent measurement of levels, which was not in accord with recommended practice. Frequent monitoring of serum levels to support dosing decisions is important to inform better clinical decision making, especially when a loading strategy is used. This may explain the less than optimal outcomes (with respect to rapid resolution of mania and hospital discharge) that were found, irrespective of dosing strategy.

[Cessation of epileptic seizures series using peroral valproate in an adult patient with partial epilepsy]

INTRODUCTION

Golden rule for the initiation of antiepileptic therapy in the majority of epileptic syndromes is "start low and go slow", a principle after the second unprovoked seizure. There are certain clinical situations however when fast titration of antiepileptic medication is needed.

CASE REPORT

We present a case of the 48-year-old man referred for further management of uncontrolled partial seizures. At the age of 37 years, he had subarachnoid haemorrhage, due to aneurysm rupture of the left internal carotid artery, with consecutive vasospasm and right haemiparesis. Since that time he had received phenobarbital 100 mg nocte. On examination he had a right sided upper motor neuron weakness affecting the arm more than the leg, and mild dysarthria, EEG investigation showed frequent transitory spikewaves discharges above the left hemisphere with the fast contralateral propagation with generalised discharges and CT showed old infarction in distribution of left medial cerebral artery. Valproate therapy was initiated with the retard form in the loading dose of 2000 mg. Seizures stopped in 7th hours after the treatment initiation. Laboratory parameters (liver function tests, blood count, level of antiepileptic drugs) were monitored every day. No further seizures were recorded. The patient was discharged from the hospital after 15 days in excellent condition.

CONCLUSION

In selected clinical conditions it is possible to apply the protocol for valproate loading and switch-off from the previous antiepileptic drugs to valproate monotherapy. Adverse effects are rare and mild but potentially serious, and close monitoring of clinical and laboratory parameters is necessary. Hence, a rapid switch to valproate monotherapy can be done safely only in an inpatient setting.

Safety and efficacy of rapid dose administration of quetiapine in bipolar mania

In this open-label pilot study, 20 adult patients hospitalized for acute bipolar mania received oral quetiapine as a single evening dose of 200 mg on day 1, increased by 200 mg/day on days 2, 3, and 4 until 800 mg/day taken in 2 divided doses on day 4. From day 5 onward, patients received a flexible total dose of 400-800 mg/day until completion of 3 weeks of treatment. Safety and tolerability were assessed by adverse-event (AE)-related dropouts in week 1, incidence of AEs including EPS, changes in electrocardiogram, and vital signs. Efficacy was assessed using the YMRS, PANSS, and CGI scales. Nineteen of 20 patients (95%) completed the quetiapine rapid titration during week 1. Significant improvement was observed in YMRS, PANSS, and CGI Severity of Illness scores by day 5, and was maintained throughout the study. A reduction of > or = 50% in YMRS score was achieved by 75% of patients by day 7, and maintained to day 21. Overall, 20% of patients discontinued due to AEs. Agitation was the most common cause of AE-related study discontinuation. Thirty-five per cent of patients required dose adjustment due to AEs after rapid dose administration was completed. Most patients tolerated rapid titration of quetiapine to 800 mg/day by day 4 of therapy, with a significant improvement in manic symptoms by day 7 of treatment.

Polytherapy in bipolar disorder

Bipolar disorder is a life-long condition that is associated with frequent recurrence/relapse of symptoms. Although putative mood stabilisers, such as lithium, are considered to improve the natural course of bipolar disorder, complete long-term remission is rarely achieved. In order to effectively control mood symptoms and to reduce relapse, clinicians often use polypharmacy to treat patients with bipolar disorder. In this article, we examine the recent literature on treatment strategies in bipolar disorder to determine if combination treatments provide additional benefit over monotherapy for the management of various phases of bipolar disorder. The evidence suggests that for acute mania a combination of lithium or valproate and an atypical antipsychotic is the most effective approach, with approximately 20% more patients responding to the combination than to monotherapy with any antimanic agent. Few studies have examined the use of combination therapy in comparison to monotherapy for bipolar depression. The limited evidence suggests that lithium plus an antidepressant appears to be more effective than lithium alone in those with lower serum lithium concentrations. Similarly, the combination of olanzapine plus fluoxetine is more effective than olanzapine alone. There is consensus that antidepressant monotherapy is not appropriate because of concerns of a manic switch, but monotherapy with lithium or lamotrigine may be adequate for mild to moderate bipolar depression. For maintenance treatment, commonly used agents, such as lithium, valproate or olanzapine appear to be most effective in preventing manic relapses, whereas lamotrigine is more effective in preventing depressive relapses. As a result of these findings, it makes intuitive sense to combine lamotrigine with lithium, valproate or an atypical antipsychotic to achieve better mood stability. However, the efficacy and safety of such combinations have not been systematically compared with monotherapy. Preliminary studies suggest that lithium plus valproate may be more effective than lithium alone in preventing affective relapses. Similarly, the combination of lithium or valproate plus olanzapine seems to be more effective than monotherapy with a mood stabiliser in preventing manic episodes.

Pharmacotherapy of bipolar mixed states

OBJECTIVE

Mixed episodes comprise up to 40% of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options.

METHOD

Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state(s), mixed episode(s), treatment, therapy, study or trial.

RESULTS

Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a sub-group of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms.

CONCLUSIONS

More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target select aspects of these episodes.

Valproate in bipolar disorder: 2000 onwards

OBJECTIVE

To describe the evidence for the efficacy and tolerability of valproate in treatment of bipolar disorders, as well as factors associated with favorable or unfavorable outcomes.

METHOD

Studies published from 2000 onwards were reviewed, as well as published abstracts. For clinical trials, randomized, prospective studies were emphasized.

RESULTS

Several mechanisms of action of valproate on central nervous system neurons that may be relevant to its actions in bipolar disorders have been recently reported. These include inhibition of glycogen synthase kinase and activation of extracellular signal-regulated kinase. Several of the actions overlap those observed from lithium. Valproate is effective in treatment of mania, and somewhat more effective in certain patient subgroups than other treatments, e.g. mixed mania, and mania with prominent irritability. Valproate is comparable with olanzapine in maintenance treatment, and somewhat better tolerated. Higher serum levels, particularly above 110 microg/ml, are associated with more reports of weight gain, sedation, and reductions in platelet count. Valproate may be associated with an increased rate of polycystic ovarian syndrome, with increased weight contributing to the risk. Valproate reduces total cholesterol levels, particularly among patients with baseline elevations of cholesterol. Several studies indicate that valproate can be beneficially combined with antipsychotic drugs and other treatments for bipolar disorder.

CONCLUSION

Valproate continues to be studied in further clarification of its mechanisms, efficacy, risks, and spectrum of benefits in bipolar disorder. It is a major treatment for bipolar disorder, both in monotherapy and combination therapy regimens.

Treatment of acute mania

Mood stabilizers have evolved considerably over the past decade. Lithium, divalproex, and olanzapine are currently Food and Drug Administration-approved for the treatment of acute mania. A number of new and traditional medications have also been tested and are commonly used in clinical practice. Several strategies for managing treatment-resistant mania have been suggested, but few have been rigorously tested. Emphases on rapid stabilization and fewer side effects have raised the bar for what is expected from mood stabilizers and the successful treatment of mania involves a delicate balance between swiftness, short-term tolerability, and long-term safety.