From the Guidelines
A pharmacist should provide comprehensive medication management guidance to PCPs treating bipolar disorder patients, prioritizing first-line treatments such as lithium, valproate, or second-generation antipsychotics like quetiapine, while emphasizing necessary monitoring, potential drug interactions, and side effect management. When guiding PCPs, pharmacists should consider the patient's specific needs, including their medical history, current medications, and potential contraindications.
Key Considerations for Medication Management
- Lithium: starting at 300mg daily, titrating to therapeutic levels of 0.6-1.2 mEq/L, with monitoring of renal and thyroid function 1
- Valproate: starting at 250mg twice daily, targeting 50-125 μg/mL, with monitoring of liver function 1
- Second-generation antipsychotics: such as quetiapine, starting at 50mg daily, increasing to 300-800mg daily, with monitoring of metabolic parameters 1
Monitoring and Management
- Baseline and follow-up monitoring of renal and thyroid function for lithium, liver function for valproate, and metabolic parameters for antipsychotics
- Highlighting potential drug interactions, such as NSAIDs increasing lithium levels or enzyme-inducing medications affecting valproate efficacy
- Providing guidance on managing side effects, recommending appropriate dose adjustments for special populations (elderly, hepatic/renal impairment), and suggesting strategies for improving medication adherence
Collaborative Approach
Pharmacists should work closely with PCPs to optimize treatment outcomes while minimizing adverse effects in bipolar disorder management, as supported by the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. This collaborative approach leverages the pharmacist's medication expertise to provide comprehensive guidance on medication management, ultimately improving patient outcomes.
From the FDA Drug Label
The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive-compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients Screening Patients for Bipolar Disorder: A major depressive episode may be the initial presentation of bipolar disorder It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder.
Guidance for Pharmacists: When treating patients with bipolar disorder, the pharmacist should advise the PCP to:
- Screen patients for bipolar disorder before initiating treatment with an antidepressant, including a detailed psychiatric history and family history of suicide, bipolar disorder, and depression.
- Monitor patients closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of treatment or at times of dose changes.
- Consider the potential risks of treating a major depressive episode with an antidepressant alone in patients at risk for bipolar disorder, as it may increase the likelihood of precipitation of a mixed/manic episode.
- Refer to the full prescribing information for the specific medication being used, such as olanzapine 2 or quetiapine 3, for guidance on dosage, administration, and potential side effects.
From the Research
Guidance for PCP Treating Patients with Bipolar Disorder
A pharmacist should provide the following guidance to a Primary Care Physician (PCP) treating patients with bipolar disorder:
- Ensure accurate diagnosis, as patients are often misdiagnosed in primary care settings 4
- Provide evidence-based approach to screening, diagnosis, and pharmacological management of bipolar disorder 4
- Consider helping patients connect with higher levels of specialty psychiatric care when clinically indicated 4
Pharmacological Management
- First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 5
- Lithium may be effective in treating acute mania and preventing both manic and depressive episodes, especially in patients with a positive family history for bipolar disorder, mania-depression-interval pattern, few previous affective episodes/hospitalizations, high risk for suicide, and no comorbidities 6
- Valproate may be more effective as an antimanic rather than prophylactic agent, especially in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 6
- Combination therapy with lithium and valproate may be more effective than monotherapy with either drug alone for relapse prevention in bipolar I disorder 7
Treatment Considerations
- Antidepressants are not recommended as monotherapy for bipolar disorder 5
- Consider the risk of early mortality, cardiovascular disease, and metabolic syndrome when treating patients with bipolar disorder 5
- Monitor patients for adherence to treatment, as more than 50% of patients with bipolar disorder are not adherent to treatment 5
- Be aware of the potential for suicidal behavior, as approximately 15% to 20% of people with bipolar disorder die by suicide 5