1
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Olivola M, Civardi S, Damiani S, Cipriani N, Silva A, Donadeo A, Politi P, Brondino N. Effectiveness and safety of intravenous valproate in agitation: a systematic review. Psychopharmacology (Berl) 2022; 239:339-350. [PMID: 34783884 DOI: 10.1007/s00213-021-06009-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
RATIONALE The use of intravenous valproate is not approved for clinical practice in psychiatry. Literature data pointed out for a potential usefulness of this route of administration for valproate, but there is no actual consensus. OBJECTIVES The aim of the present systematic review is to assess the effectiveness of intravenous valproate in agitation as well as general safety. METHODS A systematic review of studies evaluating the use of intravenous valproate in agitation was conducted. Additionally, safety was evaluated in all randomized trials involving the use of intravenous valproate in all medical conditions (epilepsy, migraine and psychiatric conditions). RESULTS For the systematic review on effectiveness in agitation, the search yielded 965 articles overall. After removing duplicates, 9411 articles were screened by title and abstract, and 39 of these were evaluated at a full-text level. Six studies were considered eligible for qualitative synthesis: one RCT and case report (n = 3), followed by cohort studies (n = 2). For the systematic review on safety, twenty-two RCTs were considered eligible for quantitative synthesis. CONCLUSION Intravenous valproate seems efficacious in reducing agitation in psychiatric patients; it generally appears safe compared to other neuroleptics or antiepileptics. However, the evidence is still not strong as it relies mainly on open-label studies or case series.
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Affiliation(s)
- Miriam Olivola
- ASST Pavia, Pavia, Italy. .,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Serena Civardi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Stefano Damiani
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Nicolo Cipriani
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genova, Italy
| | - Andrea Silva
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Alberto Donadeo
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Pierluigi Politi
- ASST Pavia, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Natascia Brondino
- ASST Pavia, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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2
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Abstract
Despite the relatively high prevalence of mixed symptoms and features among patients with mood disorders, the current literature supporting the specific efficacy of second-generation antipsychotics and mood stabilizers for the treatment of mixed symptoms is limited. Several studies have demonstrated that acute affective episodes with mixed symptoms or features tend to respond unsatisfactory to treatments that are usually more effective for the management of other affective phases. There is clearly a need for clinical trials in order to determine the more adequate pharmacologic option for the treatment of individuals suffering from affective episodes with mixed features.
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Affiliation(s)
- Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Gustavo H Vazquez
- Department of Psychiatry, Queen's University, 752 King Street West, Kingston, Ontario K7L 4X3, Canada; International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA
| | - Alberto Forte
- International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA; Department Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Debbi Ann Morrissette
- Neuroscience Education Institute, 5900 La Place Court, Suite 120, Carlsbad, CA 92008, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA; University of Cambridge, Cambridge, UK
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3
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Fontana E, Mandolini GM, Delvecchio G, Bressi C, Soares JC, Brambilla P. Intravenous valproate in the treatment of acute manic episode in bipolar disorder: A review. J Affect Disord 2020; 260:738-43. [PMID: 31581039 DOI: 10.1016/j.jad.2019.08.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/20/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mania is a state of elated or irritable mood characterizing Bipolar Disorder type I (BD-I). Among the pharmacological treatments for the management of mania, mood stabilizers are regularly employed, with valproate being one of the most used because of its effectiveness. However, while the oral formulation is approved for acute mania, it is unclear whether the intravenous (IV) formulation could be a valid and safe alternative. METHODS We performed a bibliographic research on PUBMED of all studies investigating the use of IV valproate as a treatment of acute mania in BD-I. A total of 13 studies met our inclusion criteria. RESULTS Overall, the results suggest that IV valproate as a loading therapy is an efficacious, safe and well tolerated treatment for manic episodes, and it is comparable to the oral loading regimen. Interestingly, only a few patients experienced significant side effects due to the administration of the IV valproate. LIMITATIONS Few open label clinical trials have explored the effect of IV valproate in manic patients. Moreover, the original studies employed different clinical assessments and included manic patients taking other drugs, which made it impossible to determine whether the resolution of symptoms was due to valproate therapy alone. Additionally, serum valproate levels were not assessed by all studies. CONCLUSIONS IV valproate may represent a valid option for the management of acute mania, with comparable effects in terms of efficacy and safety to the oral valproate. However, larger and more homogeneous studies are warranted in order to collect more precise information on the beneficial effect of IV valproate.
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4
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Battaglia C, Averna R, Labonia M, Riccioni A, Vicari S. Intravenous Valproic Acid Add-On Therapy in Acute Agitation Adolescents With Suspected Substance Abuse: A Report of Six Cases. Clin Neuropharmacol 2018; 41:38-42. [PMID: 29303801 DOI: 10.1097/WNF.0000000000000265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of this study was to test efficacy and safety of intravenous (IV) valproate for aggression in children and adolescents with mood or conduct disorder and concomitant substance abuse. Six patients received a 20 mg/kg dose of IV valproic acid as an add-on therapy to their standard therapy with second-generation antipsychotics and benzodiazepines. Agitation and general psychopathology were measured at baseline and after the first injection using the Modified Overt Aggression Scale, the Brief Psychiatric Rating Scale, and the Children's Global Assessment Scale. The findings suggested that in emergency psychiatry clinical settings, IV valproate was effective in reducing agitation and aggressive behaviors with a good tolerability profile and better treatment compliance.
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5
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Verdolini N, Hidalgo-Mazzei D, Murru A, Pacchiarotti I, Samalin L, Young AH, Vieta E, Carvalho AF. Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines. Acta Psychiatr Scand 2018; 138:196-222. [PMID: 29756288 DOI: 10.1111/acps.12896] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states. METHOD The MEDLINE/PubMed and EMBASE databases were systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II. RESULTS The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood-stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines. CONCLUSION The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.
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Affiliation(s)
- N Verdolini
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,FIDMAG Germanes Hospitalàries Research Foundation, Sant Boi de Llobregat, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain.,Division of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - D Hidalgo-Mazzei
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain.,Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A Murru
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - I Pacchiarotti
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - L Samalin
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,Department of Psychiatry, CHU Clermont-Ferrand, University of Auvergne, Clermont-Ferrand, France.,Fondation FondaMental, Pôle de Psychiatrie, Hôpital Albert Chenevier, Créteil, France
| | - A H Young
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - E Vieta
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - A F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre of Addiction and Mental Health (CAMH), Toronto, ON, Canada
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6
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Azorin JM, Yatham L, Mosolov S, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry 2018; 19:2-58. [PMID: 29098925 DOI: 10.1080/15622975.2017.1384850] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults. METHODS Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode. RESULTS Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention. LIMITATIONS The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands. CONCLUSIONS Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
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Affiliation(s)
- Heinz Grunze
- a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK
- b Paracelsus Medical University , Nuremberg , Germany
- c Zentrum für Psychiatrie Weinsberg , Klinikum am Weissenhof , Weinsberg , Germany
| | - Eduard Vieta
- d Bipolar Disorders Programme, Institute of Neuroscience , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Guy M Goodwin
- e Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Charles Bowden
- f Dept. of Psychiatry , University of Texas Health Science Center , San Antonio , TX , USA
| | - Rasmus W Licht
- g Psychiatric Research Unit, Psychiatry , Aalborg University Hospital , Aalborg , Denmark
- h Clinical Department of Medicine , Aalborg University , Aalborg , Denmark
| | - Jean-Michel Azorin
- i Department of Psychiatry , Hospital Ste. Marguerite , Marseille , France
| | - Lakshmi Yatham
- j Department of Psychiatry , University of British Columbia , Vancouver , BC , Canada
| | - Sergey Mosolov
- k Department for Therapy of Mental Disorders , Moscow Research Institute of Psychiatry , Moscow , Russia
| | - Hans-Jürgen Möller
- l Department of Psychiatry and Psychotherapy , Ludwigs-Maximilian University , Munich , Germany
| | - Siegfried Kasper
- m Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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7
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Abstract
Weight gain is a side-effect commonly associated with drugs used for headache prophylaxis. Weight gain can adversely affect patient health, exacerbate comorbid metabolic disorders and encourage noncompliance. Few studies have been conducted specifically on the effect of headache medications on weight, and it is important for physicians to have accurate information about weight-gain side-effects when identifying appropriate pharmacological regimens. This review discusses the potential effects on weight of the more common headache medications.
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Affiliation(s)
- W B Young
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
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8
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Ghaleiha A, Haghighi M, Sharifmehr M, Jahangard L, Ahmadpanah M, Bajoghli H, Holsboer-Trachsler E, Brand S. Oral loading of sodium valproate compared to intravenous loading and oral maintenance in acutely manic bipolar patients. Neuropsychobiology 2015; 70:29-35. [PMID: 25171133 DOI: 10.1159/000363344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/28/2014] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ali Ghaleiha
- Research Center for Behavioral Disorders and Substances Abuse, Hamadan University of Medical Sciences, Hamadan, Iran
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9
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Asadollahi S, Heidari K, Hatamabadi H, Vafaee R, Yunesian S, Azadbakht A, Mirmohseni L. Efficacy and safety of valproic acid versus haloperidol in patients with acute agitation: results of a randomized, double-blind, parallel-group trial. Int Clin Psychopharmacol 2015; 30:142-50. [PMID: 25500684 DOI: 10.1097/YIC.0000000000000064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to compare the efficacy of valproate versus haloperidol in decreasing the agitation level in affected patients in the emergency department. We assigned 80 acutely agitated patients to receive either intravenous sodium valproate (20 mg/kg) or intramuscular haloperidol (5 mg/1 ml). Agitation was measured at baseline and 30 min after the first injection using the Agitation-Calmness Evaluation Scale (ACES), the Positive and Negative Syndrome Scale-Excited Component subscale, and the Agitated Behavior Scale. For 80 patients treated with sodium valproate, the mean ± SD dosage was 1541.5 ± 286 mg (range 940-2400). The mean postintervention ACES scores from baseline to 30 min after drug injection were 4.73 (SD = 1.93) for the valproate group and 5.45 (SD = 2.09) for the haloperidol group (P = 0.028). No significant differences were observed in terms of the mean changes 30 min after the intervention for two additional agitation scales. A larger proportion of patients in the haloperidol group experienced intense sedation (36.2%, P < 0.001) and extrapyramidal symptoms (8.7%, P = 0.007) compared with the valproate group (2.5% for intense sedation, no patient for extrapyramidal symptoms). The findings suggest that in the clinical practice setting of emergency psychiatry, intravenous valproate is as effective as haloperidol in reducing agitation, with a better safety profile.
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10
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Abstract
Although much progress has been made in successfully treating bipolar disorder, there is increasing awareness of the limitations of traditional treatment regimens such as lithium and neuroleptics. The large family of anticonvulsant drugs, however, appears to be capable of providing new treatment options, not only as medication of second choice in patients refractory to treatment, but often as a treatment standard with high efficacy and low incidence of side effects. Besides established mood stabilizers such as carbamazepine and valproate, new antiepileptic drugs are entering the field with promising initial results in the treatment of bipolar patients. Furthermore, bringing to light the mechanisms of action of anticonvulsants and the similarities between anticonvulsants effective in bipolar disorder may also deepen our understanding of the pathophysiological basis of the disorder.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, University of Munich, Germany
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11
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Moller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania. World J Biol Psychiatry 2009; 10:85-116. [PMID: 19347775 DOI: 10.1080/15622970902823202] [Citation(s) in RCA: 214] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
These updated guidelines are based on a first edition that was published in 2003, and have been edited and updated with the available scientific evidence until end of 2008. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania in adults. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A-F). As these guidelines are intended for clinical use, the scientific evidence was finally asigned different grades of recommendation to ensure practicability.
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Affiliation(s)
- Heinz Grunze
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.
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12
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Abstract
OBJECTIVE To review the literature on the effectiveness of anticonvulsant drugs in the management of bipolar disorder. METHODS A selective review of the literature. RESULTS Valproate is an effective drug, alone or in combination, for mania, but has limited benefit in bipolar depression. Although valproate is widely used in maintenance therapy of bipolar disorder, and secondary analyses suggest benefit, in the largest randomised maintenance trial there was only a trend favouring valproate. Lamotrigine has benefit in bipolar depression and maintenance, but not in mania. Carbamazepine is effective in mania. Other anticonvulsant drugs have been tried in mania, but with mixed results. CONCLUSIONS Valproate, lamotrigine and carbamazepine have a valuable place in the management of bipolar disorder.
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Affiliation(s)
- Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 78229-3900, USA.
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13
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Abstract
OBJECTIVE To report a case of severe circulatory collapse following an intravenous injection of sodium valproate. CASE SUMMARY A 5-year-old white girl, who was receiving vasopressor support, developed a severe circulatory collapse following an intravenous injection of valproate 480 mg. Her invasive arterial blood pressure dropped after valproate was started, and she went into cardiac arrest requiring full resuscitation including 2 doses of epinephrine. She was successfully resuscitated. DISCUSSION To the best of our knowledge, this is the first case report of such severe circulatory collapse associated with intravenous valproate. Although hypotension has been reported following the use of intravenous valproate, severe circulatory compromise leading to cardiorespiratory arrest has not been previously described. An objective causality assessment using the Naranjo probability scale revealed that the adverse drug event was highly possible. CONCLUSIONS In view of this patient's circulatory collapse associated with valproate, intravenous sodium valproate should be used with caution, particularly in hemodynamically unstable patients.
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Affiliation(s)
- Prashant Kumar
- Department of Paediatrics, Royal Victoria Infirmary, Newcastle upon Tyne, England.
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14
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Abstract
OBJECTIVES This article summarizes the role of valproate as a treatment for bipolar disorder and related conditions. METHODS Published studies and reviews were systematically reviewed. Results from randomized, parallel group, double-blind, placebo-controlled studies that included an active comparator are emphasized. RESULTS Valproate is an effective treatment for manic patients. Valproate was superior to placebo in one 1-year randomized, parallel group study in rate of recurrence requiring discontinuation, rate of depression requiring discontinuation, total early termination and time to 25% of patients relapsing with mania, and in controlling mild depressive symptoms. On some measures, including time to development of a manic episode, valproate did not differ from placebo. Assessments of maintenance efficacy of valproate and other putative prophylactic treatments for bipolar disorder are problematic, because of the need to analyze multiple indices of efficacy, and practical and ethical issues that limit generalizability of results of placebo-controlled studies. Valproate has some advantages over lithium in treatment of mania for persons with more severe illnesses. Valproate benefits a broader spectrum of bipolar conditions than lithium. Valproate appears at best modestly effective for bipolar depression. Used in combination with several other treatments, additive benefits result, that are greater than with any of the treatments as monotherapy. Side effects are generally mild and manageable, particularly with divalproex. Weight gain and pharmacokinetic interaction with lamotrigine are perhaps the most consistent problems in use. Valproate contributes to neural tube defects if taken during the first trimester of pregnancy, and this risk must be conveyed to women. CONCLUSIONS Valproate is an effective and useful treatment for bipolar disorder. Studies clarifying its spectrum of efficacy, its safety and efficacy in combination regimens, and its mechanisms of action are warranted.
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Affiliation(s)
- Charles L Bowden
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, 78229, USA.
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15
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Jagadheesan K, Duggal HS, Gupta SC, Basu S, Ranjan S, Sandil R, Akhtar S, Nizamie SH. Acute antimanic efficacy and safety of intravenous valproate loading therapy: an open-label study. Neuropsychobiology 2003; 47:90-3. [PMID: 12707491 DOI: 10.1159/000070015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This open-label study investigated whether acute antimanic effects and safety of intravenous valproate loading therapy is superior to oral valproate loading. Eighteen patients with DSM-IV diagnosis of either bipolar affective disorder or schizomania who met the study criteria were recruited (9 in the intravenous and 9 in the oral valproate group). Psychopathology was assessed with the scale for manic and mixed states on days 0 and 4. A checklist was used for the assessment of side effects. The results showed about 36% reduction in total mean manic scores with intravenous valproate loading; however, statistically, the degree of reduction in manic scores was comparable between the groups. A nonsignificant increase in the rate of adverse events was noted in the intravenous group. Despite its limitations, this study suggests that acute antimanic effects of both intravenous and oral valproate loading are comparable.
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16
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Abstract
Substance P (SP) is a neuropeptide which is widely distributed in the periphery and the central nervous system (CNS), where it is co-localised with other neurotransmitters such as serotonin or dopamine and where it acts as a neuromodulator. SP has been proposed to play a role in the aetiopathology of asthma, inflammatory bowel disease, emesis, psoriasis, as well as neuropsychiatric disorders including pain syndromes (e.g. migraine and fibromyalgia) and affective disorders, anxiety disorders, schizophrenia and Alzheimer's disease. This review focuses on the role of SP in the pathogenesis of affective disorders. It summarises the current knowledge on measurements of SP in the CSF and serum in patients with depressive disorders or fibromyalgia, effects of SP-application in humans, SP-receptor expression in postmortem brains and the modulation of SP levels in the course of antidepressant treatment. It also discusses the promise of substance P-receptor antagonists (SPA) for the treatment of affective disorders and their proposed mechanism of action. In summary, much more research is needed to elucidate the role of SP in the pathogenesis of depression. SPA are promising as future drugs for the treatment of affective disorders, but current clinical trials have yet to be completed to draw a firm conclusion. Key words: substance P, neurokinin1-receptor, affective disorders, depression, review.
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Affiliation(s)
- Inga Herpfer
- Department of Psychiatry and Psychotherapy, University of Freiburg, Germany
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17
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Grunze H, Kasper S, Goodwin G, Bowden C, Baldwin D, Licht RW, Vieta E, Möller HJ. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania. World J Biol Psychiatry 2003; 4:5-13. [PMID: 12582971 DOI: 10.3109/15622970309167904] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Identical to the preceding guidelines of this series, these practice guidelines for the biological, mainly pharmacological treatment of acute bipolar mania were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was finally not only graded, but has also been commented by the experts of the task force to ensure practicability. Key words: bipolar disorder, mania, acute treatment, evidence-based guidelines, pharmacotherapy, antipsychotics, mood stabiliser, electroconvulsive therapy.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany.
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18
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Abstract
OBJECTIVE This double-blind pilot study compares the effectiveness and incidence of adverse effects of oral loading versus titration schedules of valproate in acute mania. METHOD Consecutive new admissions for an acute manic episode were prescribed either an oral loading dose (20 mg/kg/day; n = 5; mean age = 33.4) or slower titration dose (10 mg/kg/day, n = 6. mean age = 30.6) of valproate for 7 days without other psychotropic agents. with the exception of benzodiazepines. Daily outcome measures included: serum valproic acid levels, the Young Mania Rating Scale (YMRS), the Brief Psychiatry Rating Scale (BPRS), the Clinical Global Impression Scale (CGI) and the Adverse Effect Rating Scale. RESULTS The mean serum valproic acid levels were significantly higher in the loading group when compared with the titration group after 1 and 2 days following the initiation of treatment (p < 0.05). After 3 days of treatment there was a trend for the group that received the loading regimen to have slightly more improvement in YMRS scores compared with the titration group. Side-effects were minor for both treatments, however, a higher incidence of side-effects was reported in the titration group, with 50% of patients reporting sedation most likely because of increased use of benzodiazepines. CONCLUSION This suggests that a loading dose of valproate is likely safe and may provide an earlier onset of antimanic effects in patients with bipolar disorder. Future studies with larger sample sizes are indicated.
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Affiliation(s)
- O J Oluboka
- Department of Psychiatry Dalhousie University, Halifax NS, Canada.
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19
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Abstract
BACKGROUND The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental management of patients who have bipolar I disorder, or BD, previously known as manic-depressive disorder. TYPES OF STUDIES REVIEWED The authors conducted a MEDLINE search for the period 1995 through 2001 using the key terms "bipolar disorder," "epidemiology," "pathophysiology," "treatment" and "dentistry." The articles they selected for further review included those published in English in peer-reviewed journals; they gave preference to articles reporting randomized, controlled trials. RESULTS BD is a psychiatric illness characterized by extreme mood swings. Mania is accompanied by euphoria, grandiosity, racing thoughts and lack of insight. Depression is characterized by marked sadness or loss of interest or pleasure in daily activities. The unpredictable mood swings can distress the person, can impair social function and quality of life and are associated with a significant increase in the risk for substance abuse and suicide. BD is common in the United States, with a lifetime prevalence rate of 1.6 percent and recurrence rate of more than 50 percent. CLINICAL IMPLICATIONS The prevalence of dental disease usually is extensive because of poor oral hygiene and medication-induced xerostomia. Preventive dental education, saliva substitutes and anticaries agents are indicated. To avoid adverse drug interactions with the usually prescribed psychiatric medications, special precautions should be taken when administering certain antibiotics, analgesics and sedatives.
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20
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Abstract
Substance P (SP) is a neuropeptide which is abundant in the periphery and the central nervous system, where it is colocalized with other neurotransmitters such as serotonin or dopamine. SP has been proposed to play a role in the regulation of pain including migraine and fibromyalgia, asthma, inflammatory bowel disease, emesis, psoriasis as well as in central nervous system disorders. This review summarizes our current knowledge of the role of SP in the pathogenesis of neuropsychiatric disorders with special emphasis on affective disorders including bipolar disorders. It also reviews current treatment approaches with neurokinin 1 receptor antagonists which appear to be promising drugs for the future treatment of affective disorders.
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Affiliation(s)
- Klaus Lieb
- Department of Psychiatry and Psychotherapy, University of Freiburg, Medical School, Germany.
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21
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Abstract
Over the past decade, the number of treatments available for bipolar disorder has undergone an extraordinary expansion. In that period, valproate and olanzapine have received regulatory approval in the United States for the acute treatment of mania, and carbamazepine has been indicated for this condition in many other countries. In addition to those agents, a number of other anticonvulsants (in particular lamotrigine, gabapentin, and topiramate) are in trials, as are the atypical antipsychotics clozapine and risperidone, and other novel compounds. This article critically reviews the evidence from controlled trials of these proposed "mood stabilizers," highlighting the strengths and limitations of the data for each compound. A major challenge to the field is the capacity to prove the prophylactic properties of agents for which effectiveness in acute mania and/or bipolar depression has been demonstrated. Finally, as the mechanisms of agents such as lithium are now becoming apparent, and the possibility of understanding the molecular defects underpinning the condition is no longer highly fanciful, the prospect of targeted therapies is considered feasible by both academia and the pharmaceutical industry.
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Affiliation(s)
- Philip B Mitchell
- School of Psychiatry, University of New South Wales, Sydney, NSW 2052, Australia
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22
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Abstract
Gamma-aminobutyric acid-induced ion transport changes in the retinal pigment epithelium are described. Valproate acts as an inhibitor of gamma-aminobutyric acid transaminase. The purpose of this study was to investigate whether early visual impairment is related to valproate in patients with and without visual symptoms. Thirty-two patients, presenting with a history of seizures currently being treated with valproate, were included in the study. A complete clinical neuroophthalmologic examination was performed, including electroretinogram and visual field test. The electroretinogram parameters of epileptic patients were compared with those of 28 age- and sex-matched healthy volunteers. There was no significant difference in ERG parameters between the two groups. The visual field and visual acuity of all patients were within normal limits. When valproate is not used in conjunction with other antiepileptic drugs and serum levels are within therapeutic levels, it does not cause electrophysiologically detectable retinal dysfunction or any functional defect in visual perception that can be determined clinically.
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Affiliation(s)
- Yasar Ozkul
- Faculty of Medicine, Department of Neurology, University of Harran, Sanliurfa, Turkey.
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23
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Abstract
Over the last two decades the Bech-Rafaelsen Mania Scale (MAS) has been used extensively in trials that have assessed the efficacy of treatments for bipolar disorder. The extent of its use makes it possible to evaluate the psychometric properties of the scale according to the principles of internal validity, reliability, and external validity. Studies of the internal validity of the MAS have demonstrated that the simple sum of the 11 items of the scale is a sufficient statistic for the assessment of the severity of manic states. Both factor analysis and latent structure analysis (the Rasch analysis) have been used to demonstrate this. The total score of the MAS has been standardised such that scores below 15 indicate hypomania, scores around 20 indicate moderate mania, and scores around 28 indicate severe mania. The inter-observer reliability has been found to be high in a number of studies conducted in various countries. The MAS has shown an acceptable external validity, in terms of both sensitivity and responsiveness. Thus, the MAS was found to be superior to the Clinical Global Impression scale with regard to responsiveness, and sensitivity has been found to be adequate, with the MAS able to demonstrate large drug-placebo differences. Based on pretreatment scores, trials of antimanic therapies can be classified into: (i) ultrashort (1 week) therapy of severe mania; (ii) short-term therapy (3 to 8 weeks) of moderate mania; (iii) short-term therapy of hypomanic or mixed bipolar states; and (iv) long-term (12 months) therapy of bipolar states. The responsiveness of MAS is such that the scale has been able to demonstrated that typical antipsychotics are effective as an ultrashort therapy of severe mania; that lithium and anticonvulsants are effective in the short-term therapy of moderate mania; and that atypical antipsychotics, electroconvulsive therapy (ECT) and transcranial magnetic stimulation seem to have promising effects in the short-term therapy of moderate mania. In contrast, the scale has been used to demonstrate that calcium antagonists (e.g. verapamil) are ineffective in the treatment of mania. MAS has also been used to add to the literature on the evidence-based effect of lithium as a short-term therapy for hypomania or mixed bipolar states and as a long-term therapy of bipolar states.
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Affiliation(s)
- Per Bech
- Psychiatric Research Unit, WHO Collaborating Centre for Mental Health, Frederiksborg General Hospital, Hillerød, Denmark.
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24
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Abstract
Sodium valproate (VPA) is used in the acute treatment of status epilepticus and mania. We studied the acute effect of VPA on cerebral energy metabolism in awake mice that received VPA 400 mg kg(-1) and [1-(13)C]glucose or [2-(13)C]acetate. At 25 min, (13)C NMR spectroscopy of brain extracts indicated inhibition of the tricarboxylic acid (TCA) cycle, as could be seen from the accumulation of [4-(13)C]glutamate and reduction in [(13)C]aspartate formation. Concomitantly, the level of ATP was reduced by 40%. To identify the enzymatic step at which the TCA cycle was inhibited [U-(14)C]alpha-ketoglutarate was injected intracerebrally. Inhibition of alpha-ketoglutarate dehydrogenase was evident at 25 min, as shown by accumulation of [(14)C]glutamate. At 45 min the inhibition of alpha-ketoglutarate dehydrogenase was reversed, shown by both (13)C- and (14)C-labeling, and the ATP level was normalized. The study shows for the first time that acute administration of VPA causes inhibition of the TCA cycle activity in vivo. The reduction in brain ATP would be expected to reduce neuronal excitability through modulation of sodium channels which may be clinically advantageous in the initial phase of VPA treatment.
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Affiliation(s)
- C U Johannessen
- Norwegian Defence Research Establishment, N-2027 Kjeller, Norway.
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25
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Abstract
Treatment of acute mania has been greatly influenced by loading strategies. Loading has potential benefits, including rapid symptom reduction in mania and a shortened length of stay. Disadvantages include an increased likelihood of adverse effects of the medications. Loading strategies for lithium, valproic acid (divalproex sodium), carbamazepine, oxcarbazepine, olanzapine, and haloperidol decanoate in the treatment of acute mania are discussed. Recent studies highlight this treatment option for selected patients. It is the unique properties of the medications that influence their use in loading. Issues in patient selection for loading strategies with each medication are also considered.
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Affiliation(s)
- B T Carroll
- Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA.
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26
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Affiliation(s)
- R J Lüttmann
- Department of Neurology, University of Münster, Münster, Germany.
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27
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Abstract
Patients with migraines have typically been given one group of medications for abortive treatment and another for preventative. In the acute situation when the patient has severe nausea it is difficult to administer medications. Intravenous medications would avoid this problem but are limited to the opiates and dihydroergotamine. The following cases demonstrate the acute treatment of migraine with intravenous valproic acid (Depacon). The oral form of valproic acid has been used as a prophylactic agent, but the intravenous form may provide an alternative for abortive care as well. The ease of administration and lack of side effects are also important considerations. Double-blind studies will help clarify the situation.
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Affiliation(s)
- J Norton
- Department of Psychiatry, University of Mississippi College of Medicine, Jackson 39216, USA
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28
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29
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Abstract
Valproic acid (VPA) is administered for a variety of indications in neurology and psychiatry. The intravenous form of VPA, valproate, has been used extensively by neurologists since the 1980s for patients with status epilepticus, as serum levels can be achieved rapidly and telemetry is not required during administration. Psychiatrists have less experience with intravenous valproate, and little is documented in the literature regarding its nonepileptic indications. Patients who are unable or unwilling to take drugs orally, or for whom rapid treatment is clinically indicated, may benefit from VPA. Neuroleptics and benzodiazepines often are given parenterally; however, they may be accompanied by side effects. Intravenous valproate was administered successfully to three patients with neuropsychiatric disorders. It is hoped that this report will increase clinicians' awareness of this important and well-tolerated treatment option.
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Affiliation(s)
- J W Norton
- Department of Neurology, University of Mississippi College of Medicine, Jackson, USA
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