Polypharmacy in psychiatry practice, volume ii


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Polypharmacy in psychiatry practice, volume ii

  1. 1. 159M.S. Ritsner (ed.), Polypharmacy in Psychiatry Practice, Volume II:Use of Polypharmacy in the “Real World”, DOI 10.1007/978-94-007-5799-8_9,© Springer Science+Business Media Dordrecht 2013Abstract The treatment of bipolar illness is complex and full of caveats for theclinician, and it seems that at least some aspects of the disorder are rather refractoryto treatment. While some agents are efficacious as monotherapy, the overall out-come is unsatisfactory. However, only specific combinations have solid evidencesupporting their efficacy. Antidepressants should only be used in combination withan antimanic agent, because they can induce switching to mania/hypomania/mixedstates/or rapid cycling when utilized as monotherapy however only fluoxetine incombination with olanzapine has data supporting its usefulness for the treatment ofbipolar depression. Adding an antipsychotic to acutely manic patients who are par-tial responders to lithium/valproate/carbamazepine is a reasonable choice. Thecombination with best data in acute bipolar depression is lithium plus lamotrigine.Patients stabilized on combination treatment might do worse if shifted to mono-therapy during maintenance, and patients refractory to monotherapy could benefitwith add on treatment with olanzapine, valproate, an antidepressant or lamotrigine,depending on the index acute phase. Combination therapy may improve treatmentoutcome but it also carries more side-effect burden. Further research is necessary aswell as the development of better guidelines and algorithms for the step-by-steprational treatment.S. Magiria • M. Siamouli • A. Iacovides • K.N. Fountoulakis, M.D., Ph.D.(*)3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki,Thessaloniki, Greecee-mail: kostas_fountoulakis@yahoo.comX. GondaDepartment of Clinical and Theoretical Mental Health, Faculty of Medicine, SemmelweisUniversity, Budapest, HungaryChapter 9Evidence Based Combination Therapyfor Bipolar DisorderStamatia Magiria, Melina Siamouli, Xenia Gonda, Apostolos Iacovides,and Konstantinos N. Fountoulakis
  2. 2. 160 S. Magiria et al.AbbreviationsBD Bipolar DisorderECT Electroconvulsive TherapyHDRS-21 Hamilton Depression Rating Scale-21Li LithiumMADRS Montgomery-Asberg Depression Rating ScaleOFC Olanzapine-fluoxetine combinationRCT Randomised Controlled StudiesYMRS Young Mania Rating Scale9.1 IntroductionThere have been made many important developments in the understanding of bipo-lar disorder (BD) and its treatment, during the recent years. The first to describemanic-depressive illness as an illness of the mind were Hippocrates (460–357 BC),Galen (131–201 AD) and Areteus from Kappadokia (second century AD) who isalso considered to be the one who saw the strong connection between mania andmelancholy and his description of manic episodes was very close to modern theo-ries, including, seasonality and psychotic features. Eventually, it was Emil Kraepelin(1856–1926) who separated manic-depressive illness from schizophrenia and estab-lished it as a nosological entity on the basis of longitudinal follow-up, heredity anda relatively favourable outcome. Lately, BD-I and II subtypes were defined anddescribed, and some more subtypes such as BD-III and IV have been suggested tofurther improve the nosology [1–3].BD (previously described as manic-depressive psychosis) according to the for-mal contemporary classification consists of a depressive episode and at least onemanic (BD-I), hypomanic (BD-II), or mixed episode. Symptoms as mood altera-tions are described for several other DSM disorders which have a bipolar character[4]. The definition ‘rapid cycling’ refers to patients who are suffering from at leastfour mood episodes in a year. Females are more often rapid-cyclers and also highersocial class subjects. In bipolar patients is common to meet psychotic featuresincluding hallucinations or delusions of any type and those features can either becongruent or non-congruent and both could occur in the context of any type of epi-sode. Substance and alcohol abuse seem to be very common problems amongpatients with BD [5]. Recent studies report that there is an important degree of psy-chosocial impairment even during the euthymic period and suggest that only aminority of them achieves a complete functional recovery [6–12].Although BD was considered, according to traditional understanding, as an epi-sodic illness with a return to premorbid level of functioning between the episodes anda favourable outcome compared to schizophrenia [13], today we know that this is notalways the case [14] and the Kraepelinian concept largely corresponds to BD-I.
  3. 3. 1619 Evidence Based Combination Therapy for Bipolar DisorderEarlier studies suggested that the classic manic-depressive psychosis had alifetime prevalence of around 1% (0.4–1.6%). However, the prevalence seems todepend on the definition, with the wider spectrum of bipolarity (‘the bipolar spec-trum’) having an overall rate of 3–6.5% [15–19].All the above put further more weight on the fact that the treatment approach toBD till now was too simplistic and unsatisfactory. Nowadays, the suboptimal out-come of mood disorders is better documented, and is related more to younger age ofonset and to substance and alcohol abuse. Another important issue is that 75% ofpatients who commit suicide were found to suffer from some type of mood disorder.The World Health Organization has recently ranked bipolar disorder amongst theten most disabling medical conditions world-wide [20].The treatment of bipolar illness still is complex and full of caveats for the clini-cians [21–23], and it seems that at least some aspects of the disorder are ratherrefractory to treatment.9.2 Combination Treatment of Acute ManiaAcute mania is the best-studied phase with a significant number of monotherapytreatment strategies existing and with solid evidence support.Concerning combination treatment, the data are few. An older study on the com-bination of haloperidol plus lithium failed to increase response rates compared tohaloperidol alone [24]. On the contrary a more recent study combining valproate orlithium with 2–12 mg haloperidol or 1–6 mg risperidone suggested that the combi-nation was more efficacious against acute mania than adding placebo (response rate50% vs. 53% vs. 35% respectively for the combined lithium-valproate sample) [25].Another study reports that the combination of lithium with haloperidol at low dose(5 mg/daily) but not at high dosage (25 mg/daily) increases the efficacy againstacute mania. Lorazepam was found to be of no effect neither on the low nor on thehigh dosage [26]. Adding haloperidol on lithium was reported to be similar toadding lorazepam [27], but this was not a placebo controlled study. Lithium pluscarbamazepine was equal to lithium plus haloperidol [28], and haloperidol pluscarbamazepine was superior to haloperidol plus lithium [29] especially in improv-ing agitation in manic patients. Olanzapine plus carbamazepine was not better thancarbamazepine alone [30] and lithium plus tamoxifen was superior to lithium alone[31]. An add-on study of gabapentin was negative [32] while another one of pheny-toin was positive but the sample size was small [33].There are also a few add-on RCTs (Randomised Controlled Studies) on the treat-ment of acute mania in patients previously considered to be partial responders tolithium or valproate.In partial responders under lithium, carbamazepine or valproate at therapeuticlevels adding 1–6 mg risperidone proved to be superior to lithium, valproate orcarbamazeprine alone (response rate: 48% vs. 31% at week 1; 61% vs. 43% atweek 3) [34]. An 8-week trial on 52 incomplete responders to lithium utilized adding
  4. 4. 162 S. Magiria et al.carbamazepine or oxcarbazepine (600–1,200 mg daily) during maintenance treatment.Although this trial was designed on patients in the ‘maintenance’ phase the designand the results are more relevant to the acute manic phase. The study sample con-stituted of manic, mixed and depressed patients. Both groups improved with theaddition of either of the two drugs, but those receiving oxcarbazepine improvedsignificantly more, also their YMRS score [35] did. In partially responsive manicpatients already receiving valproate or lithium, adding olanzapine 5–20 mg dailyimproves the outcome after 6 weeks (response rate 67.7% vs 44.7% with placebo)with a robust effect on mixed-depressive symptoms [36] and on suicidality [37]. Ina 3-weeks combination treatment study, patients under lithium (0.7–1.0 mEq/L) orvalproate (50–100 mg/mL) were randomized to receive quetiapine (up to 800 mgdaily) or placebo and the response rate was higher for the quetiapine group (54.3%vs. 32.6%) [38]. Adding up to 800 mg of quetiapine daily on lithium or valproatein partial responders, improved the response rate at week 3 (55.7% vs. 41.6% withplacebo) [39]. However a more recent 6-week RCT does not support adding que-tiapine to lithium or valproate in partial responders [40]. Adding aripiprazole onlithium (0.6–1.0 mmol/liter) or valproate (50–125 mg/ml) in partial responders pro-duced higher response rate at week 6 (62.8% vs. 48.5% concerning both lithiumand valproate groups) [41]. One study reported that adding valproate to neurolep-tics improves the outcome (70% vs. 46%) [42].Two unpublished studies of add on ziprasidone exist and are both negative con-cerning the primary outcome. The first utilized 80–120 mg ziprasidone daily vsplacebo on top of lithium [43] while the second concerned a comparison of ziprasi-done (40–80 or 80–160 mg daily) vs. placebo on top of lithium or divalproex [44].Data as an adjunctive therapy are negative for topiramate [45]. There is also onenegative study for paliperidone 3–12 mg daily as adjunctive therapy to lithium orvalproate [46].The results of a 12-week placebo controlled study on the safety and efficacy ofasenapine when added to lithium or valproate was positive. Recent trials with licar-bazepine reported negative results.A recent placebo-controlled 4-week RCT supported the efficacy and safety of thepurinergic agents allopurinol and dipyridamole adjunctive to lithium in acute bipo-lar mania [47]. Also another placebo controlled RCT supported the usefulness ofcelecoxib as an adjunct in the treatment of mixed episodes with a rapid action [48].Folic acid was also found to be useful as an adjunct to valproate [49]. A small pilotstudy suggested that adding valnoctamide 600–1,200 mg/day (which is an anticon-vulsant analog of valproate that does not undergo biotransformation to the corre-sponding free acid and in mice has been shown to be distinctly less teratogenic thanvalproate) on risperidone was more efficacious against acute mania in comparisonto risperidone plus placebo [50]. A pilot study on the usefulness of adjunctiveramelteon was positive [51].The grading of efficacy data for the acute mania/mixed treatment phase (up to12 weeks) is shown in Table 9.1.In conclusion, combination and add-on studies suggest that in acutely manicpatients partial responders to lithium, valproate or carbamazepine, a good strategy
  5. 5. 1639 Evidence Based Combination Therapy for Bipolar DisorderTable 9.1 Grading of efficacy data for the acute mania/mixed treatment phase (up to 12 weeks)Agent/modality(alphabeticalorder)Combination with:Mood stabilizer Carbamazepine Lamotrigine Lithium ValproateAripiprazole − − − GoodaGoodAsenapine − − − Good GoodHaloperidol − Fairb− Good GoodLithium − Fair − − −Olanzapine − Negative data − Good GoodOxcarbazepine − − − + −Paliperidone − − − NegativedataNegative dataQuetiapine − − − Good GoodRisperidone,oral− Good − Good GoodTopiramate Negative data − − − −Valproate − − − − −Ziprasidone − − − Negative data −aGood research-based evidence, supported by at least one placebo controlled study of sufficientmagnitude. If there are non-placebo trials controlled with a comparator and with different results,the placebo controlled is the only taken into considerationbFair research-based evidence, from at least one randomised, double-blind controlled trial which,however, fail to fulfil all the criteria above (e.g., very small sample size or no placebo control)would be to add haloperidol, risperidone, olanzapine, quetiapine or aripiprazole.Adding oxcarbazepine to lithium is also a choice. The clinician could also choose toadd alternative agents for whose usefulness data are available (purinergic agents,celecoxib, folic acid).9.3 Combination Treatment of Acute Bipolar DepressionAcute bipolar depression is not well studied, only a limited number of RCTs existand the common practice to carry the clinical data and wisdom from the treatmentof unipolar to bipolar depression is proven to be wrong. Quetiapine is the onlymonotherapy with proven efficacy.As for combination treatment, the first add on studies used imipramine as adjunc-tive therapy on lithium in bipolar depression and were negative [52–54]. More recentlyone study used imipramine or paroxetine vs placebo as add on to lithium and reportedthat antidepressants were beneficial for patients with low but not for high levels oflithium [55]. Desipramine was reported to be equal to bupropion when added on amood stabilizer [56]. Another study reported that adding venlafaxine, sertraline orbupropion on a mood stabilizer increases the response rate [57–59]. Similar findingswere reported for citalopram [60] and paroxetine and amitriptyline [61].RCTs fulfilling the modern quality standards suggest that the Olanzapine-Fluoxetine combination (OFC) is efficacious against bipolar I depression with
  6. 6. 164 S. Magiria et al.remission rates 24.5% for placebo 32.8% for olanzapine and 48.8% for the OFC.However, the study sample was small concerning the OFC arm (N = 86) [62].Another study suggested that the OFC is somewhat superior to lamotriginealthough the response rates did not differ between groups. (OFC: 68.8% vs. lam-otrigine 59.7%). Thus one could interpret this study as somewhat negative for theOFC since lamotrigine is proven to be non-effective. Secondary indices showedthat the time to response was significantly shorter for the OFC-treated patients(OFC 17 days vs. lamotrigine 23 days) and there were lesser ‘suicidal and self-injurious behavior’ among OFC treated patients (OFC, 0.5% vs. lamotrigine3.4%) [63].In a recent double-blind, placebo-controlled study, adding an antidepressant(including paroxetine) on a mood stabilizer in 179 bipolar depressed patientswas not significant better than placebo after 26 weeks of treatment and therecovery rates (23.5% in the antidepressant group vs. 27.3% in the placebogroup) and switch rates were similar. Thus this study does not support the use-fulness of adjunctive antidepressant therapy [64], while on the contrary anotherearlier one supported the usefulness of paroxetine as add on therapy [65].Adding L-sulpiride was similar to adding amitriptyline on lithium but the studywas not controlled [66]. A more recent trial reported that the combination ofrisperidone plus paroxetine was not more efficacious than either agent alone[67]. However these data should be read with caution because paroxetine playeda significant role in the design since these trials predated the negative trial ofparoxetine vs. quetiapine [68]. A more recent study reported that adding lam-otrigine to lithium was better than placebo in patients with bipolar depression atweek 8, [69] however it is doubtful that the effect persists beyond week 12 [70,71]. Another recent 8-week trial on 52 incomplete responders utilized addingcarbamazepine or oxcarbazepine (600–1,200 mg daily) during maintenancetreatment with lithium. Although this trial was on patients in ‘maintenance’phase the design and the results are more relevant to the acute depressive phasesince the study sample included depressed patients. Both groups improved withthe addition of either drug but those receiving oxcarbazepine improvedsignificantly more concerning their Montgomery-Asberg Depression RatingScale (MADRS) and Hamilton Depression Rating Scale (HDRS-21) scores[35]. A small placebo-controlled adjunctive study of aripiprazole on lithium andcitalopram was negative [72].Recently one study with ziprasidone was negative [73]. The small add on studyof leviracetam was negative [74]. A placebo controlled study suggested that inpatients with treatment-resistant bipolar depression under lithium or valproate,robust and rapid antidepressant effects resulted from a single intravenous dose ofketamine hydrochloride (an N-methyl-D-aspartate antagonist) [75].The grading of efficacy data for the acute depressive treatment phase (up to12 weeks) is shown in Table 9.2.Treatment algorithms with adding agents on a step-by-step basis are yet to beresearched adequately [71].
  7. 7. 1659 Evidence Based Combination Therapy for Bipolar DisorderTable 9.2 Grading of efficacy data for the acute depressive treatment phase (up to 12 weeks)Agent/modality(alphabeticalorder)Combination with:Mood stabilizer Carbamazepine Lamotrigine Lithium ValproateAripiprazole − − − Negative data −Bupropion − Negative data − Negative data Negative dataLamotrigine − − − Gooda−Lithium − − Good − −Oxcarbazepine − − − Fairb−Paroxetine Negative data Negative data − Negative data Negative dataZiprasidone Negative data − − − −aGood research-based evidence, supported by at least one placebo controlled study of sufficientmagnitude. If there are non-placebo trials controlled with a comparator and with different results,the placebo controlled is the only taken into considerationbFair research-based evidence, from at least one randomised, double-blind controlled trial which,however, fail to fulfil all the criteria above (e.g., very small sample size or no placebo control)9.4 Combination Treatment During the Maintenance PhaseThree combination studies with lithium plus imipramine, carbamazepine or per-phenazine and carbamazepine or valproate plus perphenazine were negative. In thefirst one, 22 bipolar II patients in remission for at least 6 months and randomlyassigned them to lithium, imipramine, lithium plus imipramine, or placebo. Noeffect or interaction of imipramine was found in either group [54]. In the secondstudy, the combination of lithium plus carbamazepine did not produce furtherimprovement for patients although rapid cycling patients do better under combina-tion than under monotherapy (28.0% responded to lithium; 19.0% responded tocarbamazepine and 56.3% to their combination) [76]. In the third study, which wasa 6-months maintenance study with a placebo-controlled double blind design ofperphenazine plus lithium, carbamazepine, or valproate or a mood stabilizer plusplacebo in patients just remitted from an acute manic episode, the results suggestedthat patients receiving perphenazine had not a better course in comparison to thosereceiving placebo, but on the contrary they had a shorter time to depressive relapse,more drop-outs, and have increased rates of dysphoria and depressive symptoms[77].The olanzapine-fluoxetine combination (OFC) data have already been reportedabove [78].On the contrary, a recent placebo-controlled combination trial of quetiapine plusmood stabilizer during maintenance treatment, suggests that quetiapine is superiorto placebo in the prevention of manic and depressive recurrences in either manic,depressive, or mixed index episode over a period of 2-years [79, 80]. This combina-tion study appears to be the first to report prevention on both depression and maniaregardless of the type of index episode.
  8. 8. 166 S. Magiria et al.One small study of add-on gabapentin to ongoing treatment was positive howeverthe sample size was too small (N=25) [81]. The same holds true for phenytoin [82],while a small pilot study on oxcarabazepine plus lithium was negative [83].One placebo controlled 18-month discontinuation study on olanzapine as add onlithium or valproate during the 6-weeks acute phase suggested that patients whichresponded to the combination during the acute phase did not do longitudinally betterunder the combination than under monotherapy with lithium or valproate [84]. Anotherdiscontinuation 6 month RCT of the combination of mood stabilizer plus ziprasidone(80–160 mg/day) vs mood stabilizer alone was in favour of the combination (relapse rate19.7% vs 32.4%; longer median time to intervention for the combination: 43.0 days vs.26.5 days) [85, 86]. Refractory patients to lithium or valproate during the acute phase arereported to benefit from continuation treatment with adjunctive aripiprazole [87].The recently published BALANCE could neither reliably confirm nor refute abenefit of combination therapy compared with lithium monotherapy [88] at leastpartially because of methodological flaws [89].Add on studies suggest that at least some strategies could be useful in patientswith inadequate response to monotherapy.One randomized add-on study suggested clozapine is superior to treatment asusual in the prevention of mania in refractory patients [90]. Adding olanzapine tolithium or valproate improves outcome [84] and may reduce suicidality [37].Another study reported that valproate was more efficacious than lithium when addedon antidepressants for the prevention of bipolar depression [91], and a recent doubleblind study suggested that adding an antidepressant (bupropion, sertraline or venla-faxine) on a mood stabilizer improved both the acute phase outcome and after 1 yearfollow up without inducing mania [59]. One study reports that adding lamotrigineto lithium was better than placebo in patients with bipolar depression [69] and itsextension with the addition of paroxetine gave some additional positive results [70].There is also one positive add on study on long acting injectable risperidone [92].A 40-week placebo controlled study of the safety and efficacy of Asenapinewhen added to lithium or valproate and a 40 week extension study of asenapine vs.olanzapine (Ares 7501007) are expected to be announced.The efficacy data for the maintenance treatment phase is shown in Table 9.3.Overall, there is no compelling data that combination treatment does better thanmonotherapy. However patients stabilized on combination treatment might do worseif shifted to monotherapy, and patients refractory to monotherapy could benefit withadd on treatment with olanzapine, valproate, an antidepressant or lamotrigine, depend-ing on the index acute phase.9.5 Combination Treatment of Mixed EpisodesMost studies include mixed patients; however they include mixed episodes togetherwith manic/hypomanic episodes. Mixed depressive cases are not usually reportedin depressive RCTs. Thus there are not much data available specifically for
  9. 9. 1679 Evidence Based Combination Therapy for Bipolar DisorderTable 9.3 Efficacy data for the maintenance treatment phaseAgent/modality(alphabeticalorder)IndexepisodeEnrichedsampleCombination with:Treatmentas usualMoodstabilizer Lamotrigine Lithium ValproateAripiprazole m Yes − − − m mLamotrigine m/d Yes − − − d −Lithium m/d No − − d − −Olanzapine m Yes − m/d − m/d m/dPerphenazine m Yes − neg − − −Quetiapine m/d Yes − m/d − m/d m/dLong-actinginjectablerisperidonem Yes m − − − −Valproate m Yes − − − − −Ziprasidone m Yes − m − m mCognitive-behavioraltherapyd No d − − − −Psychoeducation m/d No m/d − − − −m mania/mixed, d depression, m/d both mania and depressionmixed patients. Some studies report separately the outcome for mixed patients;however there is a significant question concerning methodology that is most studiesreport the response only of the manic component of the mixed episode.Adding risperidone or haloperidol on valproate or lithium significantly improvesthe manic component but there was no report on the depressive one [25]. Addingolanzapine on valproate or lithium improved both components [36].The efficacy of olanzapine versus placebo as augmentation strategy to ongoingvalproate treatment was also assessed in mixed patients during a more recent6-week, placebo-controlled RCT. This study is the only existing RCT examiningtreatment effects on mixed bipolar patients. It included 202 mixed bipolar patientsrefractory to divalproex, who were administered adjunctive olanzapine or placebo.Adjunctive olanzapine was superior to placebo in improving both manic and depres-sive symptoms. The manic component responded from day 2 and the depressivefrom day 14 [93]. A secondary analysis of this study suggested early response of acomponent (at day 2) predicted full remission of the specific component [94].The meta-analysis of the olanzapine-fluoxetine RCT against acute bipolar depres-sion [62] separated patients suffering from non-mixed versus mixed depression [95]and reported that the response rates in patients with non-mixed versus those withmixed depression were similar in the OFC arm (48.9% vs. 43.2%; odds ratio=1.24),but somewhat differed in the olanzapine arm (39.9% vs. 26.6%; odds ratio=1.84)and in the placebo arm (27.5% vs. 16.3%; OR=1.94). OFC response was indepen-dent of the number of manic/hypomanic symptoms, whereas a higher number ofbaseline concurrent manic/hypomanic symptoms predicted a lower response rate inthe olanzapine and placebo arms [95].
  10. 10. 168 S. Magiria et al.Concerning the maintenance phase, combination of quetiapine with lithiumor valproate protected from any mood episode in patients with an index mixedepisode [79].9.6 Combination Treatment of Rapid CyclingThere are no studies investigating the efficacy of treatment modalities in rapidcycling patients. All the data we have comes from post-hoc and meta-analytic stud-ies and are poor concerning the overall response of the disorder.Combination of lithium plus carbamazepine is better for rapid cycling patientsdo better under combination than under monotherapy (28.0% responded to lithium;19.0% responded to carbamazepine and 56.3% to their combination) but not fornon-rapid cyclers [76]. A 6-months study comparing lithium monotherapy vs. lith-ium plus valproate in rapid cycling patients with comorbid substance abuse reportedthat both options are equal, however the dropout rate was extremely high [96].A 12-week study of adjunct lamotrigine vs. placebo on lithium or valproate inrapid cycling depressive bipolar patients was positive [97]. Also negative was a6-month add-on study with lamotrigine vs. or placebo monotherapy on 182 patientswith rapid-cycling bipolar disorder (DSM-IV criteria) although it showed somebenefits for lamotrigine [98].From 1,742 bipolar I and II patients in the STEP-BD at entry, 32% met theDSM-IV criteria for rapid cycling in the pre-study year. Of the 1,742 patients, 551(32%) did not complete 1 year of treatment. Rapid cyclers were more likely to havefurther recurrences, although not necessarily more than four episodes per year. Atthe end of 12 months, only 5% of the patients could be classified as rapid cyclers.Antidepressant use during follow-up was associated with more frequent mood epi-sodes [99].9.7 Treatment of Comorbid ConditionsComorbidity is a significant issue in bipolar patients and often needs specific thera-peutic intervention. Often it requires to combine the standard anti-bipolar therapywith another treatment modality.Lithium can be used for the treatment of concomitants substance abuse [100,101], quetiapine for alcohol abuse [102] and anxiety symptoms [103], while risperi-done can reduce drug craving [104] and anxiety [105]. Benzodiazepines can be usedas adjunctive medication for sedation or for the treatment of anxiety, although abuse,tolerance and dependence constitute important problems. Pregabaline might be auseful agent for the treatment of anxiety disorders that commonly accompany bipo-lar illness and could substitute bendodiazepines. A significant advantage is that it isnot metabolized in the liver. Topiramate is unique because of its ability to cause
  11. 11. 1699 Evidence Based Combination Therapy for Bipolar Disorderweight loss at dosages of 50–200 mg daily. It is reported that more than 70% ofpatients taking topiramate for a mean duration of 5 months lost a mean of 5–6 kilo-grams. Thus topiramate could be useful to treat weight gain which is a commonproblem in bipolar patients [106]. Naltrexone could be useful in outpatients withbipolar disorder and alcohol dependence [107].9.8 Combination Treatment with Other Agentsand Therapeutic ModalitiesA variety of agents and treatment modalities are useful in the treatment of bipolarillness. Benzodiazepines can be used as adjunctive medication for sedation or forthe treatment of anxiety, although abuse, tolerance and dependence constituteimportant problems. Dopaminergic agents and especially pramipexole could beuseful in the treatment of bipolar depression either as monotherapy or as add ontherapy [108]. In refractory depressive patients, inositol [109] and N-acetyl cysteinefor maintenance [110, 111] could also be used as augmenting agents. Recently aplacebo-controlled study of adjunctive modafinil has been shown to improve theoutcome of bipolar depression without switching to mania or hypomania [112],however subclinical switches could be present [113]. The proof of concept study foradjunct armodafinil (the longer lasting isomer of modafinil) on lithium, valproate orolanzapine was positive [114]. Celecoxib was proved efficient an adjunct in thetreatmentofdepressiveormixedwithrapidonsetoftheeffect[48].Electroconvulsivetherapy (ECT) could be a valuable option in mania [115, 116] and in treatmentresistant bipolar depression [116, 117]. Transcranial Magnetic Stimulation espe-cially when combined with brain navigation could be efficient and well toleratedagainst refractory bipolar depression [118]. Sleep deprivation and other noninvasivecircadian-related interventions could be useful add-on treatment in order to acceler-ate and sustain antidepressant response [119]. Some data are in support of the use-fulness of omega-3 fatty acids as adjunctive therapy in bipolar depression but notmania [120–125].Naltrexone could be useful in outpatients with bipolar disorder and alcoholdependence [107].A list of agents studied for augmentation strategies is shown in Table Conclusions and Future DirectionsHistorically, the modern approach in the treatment of bipolar illness starts with lithiumwhen Frederik Lange in the late 19th century [126], and latter John Cade in 1949[127–129] used it for the treatment of affective patients. However, Mogens Schouestablished the effectiveness of Li for the treatment of Bipolar Disorder [130, 131]
  12. 12. 170 S. Magiria et al.Table 9.4 List of agents studied for augmentation strategiesAgent/modality Indication for augmentationCelecoxib Mania/mixedDopaminergic agents (pramipexole) Bipolar depressionElectroconvulsive therapy Bipolar depression or mania/mixedFolic acid Mania/mixedInositol Bipolar depressionModafinil/armodafinil Bipolar depressionN-acetyl cysteine Bipolar depressionPurinergic agents Mania/mixedSleep deprivation Bipolar depressionTranscranial magnetic stimulation Bipolar depression or mania/mixedtogether with Poul Christian Baastrup [132–134] by performing among other thingsa placebo-control discontinuation study of prophylaxis [135].Our knowledge concerning the treatment of BD has changed radically during thelast couple of decades. Earlier studies report a global and high effectiveness forolder agents on all facets of bipolar disorder and a high prevalence of switching withantidepressants, which were not confirmed by newer studies. However the subopti-mal outcome is well established and the need to go beyond the first line monother-apy treatment is pressing.Concerning the treatment of acute mania some studies suggest that combinationtherapies give equivocal results and do not support combination treatment as firstline treatment for all patients [24–30]. On the contrary, many combination andadd-on studies report that in acutely manic patients the combination of Li or val-proate with aripiprazole, olanzapine, risperidone, and maybe quetiapine or asenap-ine is recommended. Adding oxcarbazepine to lithium is also a choice. Anecdotaldata suggest the use of ECT or higher dosages of neuroleptics, but the data areinsufficient.Unfortunately, there are few data to support a valid strategy about combinationtherapy in bipolar depressive cases. Quetiapine and the OFC are the only treatmentoptions with proven efficacy against this condition. Some data on the combinationof lithium plus lamotrigine also exist.About the maintenance phase, favorable data exist concerning the OFC, quetiap-ine olanzapine or ziprasidone plus a mood stabilizer, specific antidepressants plus amood stabilizer and lithium plus lamotrigine.The paucity of data leaves the clinician with the heavy burden to decide on thebasis of clinical experience and wisdom. In this frame, existing treatment guidelinescannot be considered to rely on hard data after their first step recommendations.Future research is essential and necessary to test possible treatment approaches forrefractory patients of all kinds. Add-on studies or combination studies might givesome kind of information; however the interpretation is complex and so far failed toprovide reliable ground for decision-making.
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