What is the next step for a patient with bipolar disorder experiencing a manic episode while on maintenance therapy with lamotrigine (Lamictal)?

From the Guidelines

When a patient with bipolar disorder experiences a manic episode while on lamotrigine maintenance therapy, the recommended next step is to add an antimanic agent such as lithium, valproate, or a second-generation antipsychotic while continuing lamotrigine. For acute management, options include lithium (starting at 600-900 mg/day), valproate (starting at 750-1000 mg/day), or antipsychotics like olanzapine (5-20 mg/day), risperidone (2-6 mg/day), or quetiapine (300-800 mg/day) 1. A benzodiazepine like lorazepam (1-2 mg) may be added temporarily for agitation. Lamotrigine should be continued because abrupt discontinuation could worsen mood instability, and lamotrigine is primarily effective for depression prevention rather than mania control. Some key points to consider when choosing an antimanic agent include:

• Evidence of efficacy
• The phase of illness
• The presence of confounding presentations (e.g., rapid cycling mood swings, psychotic symptoms)
• The agent's side effect spectrum and safety
• The patient's history of medication response
• The preferences of the patient and his or her family Blood levels should be monitored for lithium (0.8-1.2 mEq/L) or valproate (50-125 μg/mL) if chosen. The patient should be reassessed frequently during acute mania, and once stabilized, the antimanic medication would typically be continued for maintenance alongside lamotrigine. This approach addresses the current manic symptoms while maintaining the depression-preventing effects of lamotrigine, as breakthrough mania during lamotrigine therapy is not unexpected given the medication's limited antimanic efficacy. It is also important to note that polypharmacy is common in the treatment of bipolar disorder, and the use of multiple medications may be necessary to achieve optimal control of symptoms 1. However, care should be taken to avoid unnecessary polypharmacy, and the patient should be closely monitored for potential side effects and interactions between medications. By taking a comprehensive and individualized approach to treatment, patients with bipolar disorder can achieve better control of their symptoms and improved quality of life.

From the FDA Drug Label

When given to a patient experiencing a manic episode, lithium may produce a normalization of symptomatology within 1 to 3 weeks. The patient is already on lamotrigine, but since lamotrigine is not mentioned in the provided drug labels as a treatment for manic episodes, and lithium is indicated for the treatment of manic episodes, consider adding lithium to the patient's treatment regimen.

• The dosage of lithium is not specified in this scenario, but according to the label, lithium may be effective in normalizing symptomatology within 1 to 3 weeks 2. Note: The provided drug labels do not directly address the next step for a patient with bipolar disorder experiencing a manic episode while on lamotrigine maintenance therapy. However, based on the available information, adding lithium could be a potential option.

From the Research

Next Steps for a Patient with Bipolar Disorder Experiencing a Manic Episode while on Lamotrigine Maintenance Therapy

• The patient's treatment plan may need to be adjusted, as lamotrigine is more effective in preventing depressive episodes than manic episodes 3, 4.
• Consider adding an antipsychotic, such as olanzapine, quetiapine, or aripiprazole, to the treatment plan, as these medications have been shown to be effective in preventing manic episodes 3, 4, 5.
• Valproate may also be considered as an alternative or adjunctive treatment, as it has been shown to be effective in acute mania and maintenance therapy for bipolar disorder 6.
• The patient's response to treatment should be closely monitored, and adjustments made as needed to prevent further manic episodes 4, 5.
• In cases of rapid cycling bipolar disorder, evidence supports the use of aripiprazole, olanzapine, quetiapine, valproate, and lamotrigine for treatment 7.

Treatment Options

• Antipsychotics:
  • Olanzapine
  • Quetiapine
  • Aripiprazole
• Anticonvulsants:
  • Valproate
  • Lamotrigine
• Mood stabilizers:
  • Lithium

Considerations

• The patient's treatment plan should be individualized based on their specific needs and response to treatment 4, 5.
• Close monitoring of the patient's condition is necessary to prevent further manic episodes and adjust treatment as needed 4, 5.