CANMAT MAB Flashcards
Tx PO de l’agitation en manie
a loading dose of divalproex, oral formulations of atypical antipsychotics, conventional antipsychotics such as haloperidol or loxapine, and/or benzodiazepines such as lorazepam may be appropriate
Tx IM de l’agitation
Because of the strength of evidence for efficacy in alleviating agitation in this population,
aripiprazole IM (level 2)
lorazepam IM (level 2)
loxapine inhaled (Level 1) olanzapine IM (level 2)
are recommended as the first‐line option.
2e ligne:
Sublingual asenapine (level 3)
haloperidol IM (level 3)
haloperidol IM + midazolam IM (level 3)
haloperidol IM + promethazine IM (level 3)
risperidone ODT (level 3)
ziprasidone IM (level 3)
1ère ligne de tx monothérapie pour manie aiguë
Approximately 50% of patients will respond to monotherapy with significant improvement in manic symptoms within 3‐4 weeks
Lithium (level 1)
quetiapine (level 1)
divalproex (level 1)
asenapine (level 1)
aripiprazole (level 1)
paliperidone (level 1 for doses >6 mg)
risperidone (level 1)
cariprazine (level 1)
Overall, these agents show comparable efficacy.
1ère ligne de tx combiné pour manie aiguë
Quétiapine + Li/Di
Aripiprazole + Li/Di (niveau 2)
Risperidone + Li/Di
Asénapine + Li/Di (niveau 2)
recommended as first‐line treatment options with greater efficacy than monotherapy with lithium or divalproex alone, especially in those with higher index severity
Monothérapie vs tx combiné pour manie aiguë
In general, combination therapy is preferred to mood stabilizer monotherapy because clinical trials suggest that on average about 20% more patients will respond to combination therapy.
There is also some evidence to suggest the benefit of combination therapy compared to atypical antipsychotic monotherapy, although there are fewer trials. Specifically, lithium plus quetiapine showed superiority to quetiapine alone
2 agents avec niveau 1 d’évidence en monothérapie pour manie NR pour tx combiné
Palipéridone, Ziprasidone
Indication de tx combiné pour manie
Combination therapy with lithium or divalproex and an atypical antipsychotic is recommended when a response is needed faster, in patients judged at risk, who have had a previous history of partial acute or prophylactic response to monotherapy or in those with more severe manic episodes.
Manie avec éléments psychotiques: effet a/n du pronostic
At least half of manic episodes are characterized by the presence of psychosis, and theories suggest that it is a nonspecific feature which improves alongside underlying manic symptoms.
While the prognosis for patients experiencing mood‐congruent psychotic features may not differ from those with an absence of psychotic symptoms, limited evidence does suggest that those with mood‐incongruent features have a more severe illness with poorer long‐term prognosis
Dépression bipolaire: temps de réponse au traitement
Across several different medications for bipolar depression, early improvement (after 2 weeks) has been found to be a reasonable predictor of overall response, whereas lack of early improvement is a more robust predictor of non‐response
Tx 1ere ligne dépression bipolaire
Quétiapine (niveau 1)
Lurasidone + Li/Di (niveau 1)
Lithium
Lamotrigine
Lurasidone
Lamotrigine (adj)
Dépression bipolaire: switch vs add-on
In principle, all things being equal, a switch is preferred over add‐on to limit the degree of polypharmacy, but the clinical reality is that medications may be helpful for some but not all components of the illness, and using rational polypharmacy via add‐on treatments is often required. For situations in which patients experience a depressive episode while already receiving an adequately dosed antidepressant, strong consideration should be given to discontinuing or switching the class of antidepressant, unless clear benefits are apparent in reducing the severity or frequency of depressive episodes.
*Penser aux différents objectifs du traitement de la MAB ex. si agent utilisé pour dépression mais aussi pour prévention manie, meilleur d’ajouter un tx antidépresseur
Risques de récurrence MAB associé à quels facteurs
With treatment, 19%‐25% of patients will experience a recurrence every year, compared to 23%‐40% of those on placebo.
Risk factors for recurrence include younger age of onset,
psychotic features
rapid cycling
more (and more frequent) previous episodes
comorbid anxiety
comorbid SUD
Persistent subthreshold symptoms also increase risk for subsequent mood episodes, and the presence of residual symptoms should therefore be an indicator of a need for further treatment optimization.
Availability of psychosocial support and lower levels of stress are also protective against recurrence.
Tx maintien MAB
Lithium (level 1), quetiapine (level 1), divalproex (level 1) and lamotrigine (level 1) monotherapies have the best combination of clinical trials, administrative data, and clinical experience to support their use as first‐line therapies for maintenance treatment of BD.
Recent data suggest that asenapine (level 2) is effective in preventing both manic and depressive episodes, and thus is recommended as a first‐line treatment. Finally, aripiprazole oral (level 2) or once monthly (level 2) is also recommended as a first‐line monotherapy in view of its efficacy in preventing any mood or manic episode as well as its safety/tolerability profile, although it has not been shown to be effective in preventing depression
Additional combination therapies included as first‐ line include quetiapine adjunctive therapy with lithium/divalproex (level 1) which has demonstrated efficacy in preventing any mood, manic or depressive episode. Aripiprazole plus lithium/divalproex (level 2) should also be considered as a first‐line option.
Quand peut-on utiliser des ISRS en MAB II?
Si dépression pure (non-mixte) et pas d’antécédent de virage hypomaniaque
Tx hypomanie en MAB II
Clinical experience suggests that all anti‐manic medications are also efficacious in hypomania. Thus, when hypomania is frequent, severe, or impairing enough to require treatment, clinicians should consider mood stabilizers such as lithium or divalproex and/or atypical antipsychotics. N‐acetylcysteine may also be of benefit, but further studies are needed.
Tx dépression en MAB II
1ere ligne: Quétiapine
2e ligne (tous niveau 2 sauf ECT)
-Lithium
-Lamotrigine
-Buproprion (adj)
-ECT (niveau 3)
-Setraline
-Venlafaxine
Tx maintien MAB II
1ere ligne:
-Quétiapine niveau 1
-Lithium niveau 2
-Lamotrigine niveau 2
2e ligne: Venlafaxine niveau 2
Rx en post-partum
There is evidence of efficacy of benzodiazepines, antipsychotics, and lithium for postpartum mania,535 and quetiapine for postpartum bipolar depression (level 4).536 There are no studies of psychotherapy in the acute or preventative treatment of bipolar postpartum depression.
Impact de la ménopause sur MAB
A post hoc analysis of the prospective Systematic Treatment Enhancement Program for Bipolar disorder (STEP‐BD) study showed increased rates of depressive, but not manic episodes during menopause transition.
Tx manie pédiatrique
Lithium (level 1), risperidone (level 1), aripiprazole (level 2), asenapine (level 2), and quetiapine (level 2) are recommended as first‐line options.
Risperidone may be preferable to lithium for non‐obese youth, and youth with ADHD.
Tx dépression bipolaire pédiatrie
1ere ligne: Lurasidone
2e ligne: Lithium, Lamotrigine
Tx maintien MAB pédiatrie
Preferred maintenance treatment options for this population are aripiprazole (level 2), lithium (level 2) and divalproex (level 2).
It is important to note that few patients continued to do well upon the switch to either lithium or divalproex monotherapy and the majority re‐responded when the combination was reinstated.
Further, other studies have also suggested the efficacy of combination therapy (eg, risperidone plus lithium or divalproex and lithium plus divalproex or carbamazepine) to achieve and maintain remission.
Adjunctive lamotrigine may also be considered for those aged ≥ 13 years (level 2).
Tx MAB et TDAH pédiatrie
Stimulants may also be used for comorbid ADHD in stable/euthymic youth taking optimal doses of anti‐manic medications. Adjunctive mixed amphetamine salts (level 3) and methylphenidate (level 3) have both been shown to be effective in addressing attention symptoms and have been well tolerated overall within the RCTs completed to date, theoretical and epidemiological data regarding risks of induction of mood elevation notwithstanding.
Although open trials suggest potential benefits of atomoxetine (level 4), the possibility of inducing mania or hypomania remains, suggesting the need for RCTs before clinical recommendations can be made.
Tx manie gériatrie
Monotherapy with lithium (level 2) or divalproex (level 2) is recommended as a first‐line treatment.
Quetiapine (level 2) can be considered as second‐line.
Asenapine (level 4), aripiprazole (level 4), risperidone (level 4), or carbamazepine (level 4) may be applied as third‐line treatments.
For treatment‐resistant episodes, clozapine (level 4) and ECT (level 4) should also be considered.
