Lamitrogine

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the role of lamotrigine in the management of bipolar disorders

the role of lamotrigine in the management of bipolar disorders

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  • 1. Lamotrigine: Update in psychiatric practice
    Walid Sarhan F.R.C.Psych.
    AMMAN-JORDAN
  • 2. Newer Antiepileptic Drugs( Second- Generation )
    Vigabatrin 1989
    Gabapentin 1993
    Lamotrigine 1994
    Topiramate 1996
    Tiagabine 1997
    levetiracetam 1999
    Oxcarbazepine 2000 (safety profile similar to CBZ). Hyponatremia is also problem, however it is less likely to cause rash than CBZ.
    Zonisamide 2000
  • 3. Description
    Lamotrigine an AED of the phenyltriazine class, is chemically unrelated to existing AEDs. Its chemical name is 3,5-diamino-6-(2,3-dichlorophenyl)-as-triazine.
    Lamotrigine is a white to pale cream-colored powder .
    Lamotrigine is soluble in water .
  • 4. Mechanism of action
    Lamotrigine inhibits voltage-sensitive sodium channels, thereby stabilizing neuronal membranes and consequently modulating presynaptic transmitter release of excitatory amino acids (e.g., glutamate and aspartate).
  • 5. Metabolism
    Lamotrigine is metabolized predominantly by glucuronic acid conjugation; the major metabolite is an inactive 2-N-glucuronide conjugate.
    After oral administration ,94% was recovered in the urine and 2% was recovered in the feces.
  • 6. INDICATIONS
    Epilepsy—adjunctive therapy in patients ≥2 years of age:
    partial seizures.
    primary generalized tonic-clonic seizures.
    generalized seizures of Lennox-Gastaut syndrome.
    Epilepsy—monotherapy in patients ≥16 years of age:
    conversion to monotherapy in patients with partial seizures who are receiving treatment with Carbamazepine, Phenobarbital, phenytoin, primidone, or Valproate as the single AED.
  • 7. INDICATIONS
    Bipolar Disorder in patients ≥18 years of age:
    maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes .
  • 8. INDICATIONS
    Acute treatment of bipolar depression I,
    Maintenance treatment for rapid-cycling BP II (no antimanic properties)
    BP I recently manic or depressed
  • 9. INDICATIONS
    Less effective for mixed episode, rapid cycling
    Borderline PD & schizoaffective disorder, also for migraine, impulsivity & compulsivity
    Bipolar II disorders, post traumatic stress disorder,
    Adjunctive therapy for "treatment-resistant" unipolar depression .
  • 10. Indications
    The treatment of peripheral neuropathy, trigeminal neuralgia, cluster headaches, migraines, and reducing neuropathic pain.
  • 11. NOTE
    Traditional anticonvulsant drugs are primarily antimanics, Lamitrogine is most effective in the treatment and prophylaxis of bipolar depression.
  • 12. Bipolar I Depression:Lamotrigine Monotherapy
    Week
    0
    0.5
    1
    2
    3
    4
    5
    6
    7
    0
    -2
    *P < .05 vs placebo
    -4
    -6
    -8
    MADRS Change From Baseline
    *
    -10
    *
    -12
    *
    *
    *
    -14
    *
    *
    *
    Placebo
    -16
    *
    Lamotrigine 50 mg/d
    -18
    Lamotrigine 200 mg/d
    -20
    Dose > 50 mg/d in lamotrigine 200 mg/d group only after week 3
    Calabrese JR, et al. J Clin Psychiatry. 2002;63(suppl 3):5-9.
  • 13. The Evidence for Lamotrigine in Rapid-Cycling Bipolar Disorder
    Lamotrigine monotherapy is useful treatment for some patients with rapid-cycling bipolar disorder
    Among patients with rapid-cycling bipolar disorder, 41% of lamotrigine patients vs 26% of placebo patients were stable without relapse for 6 months of monotherapy
    Overall survival time in study favored lamotrigine
    (6 weeks longer than placebo)
    Calabrese JR, et al. J Clin Psychiatry. 2000;61:841-850.
  • 14. 2002 American Psychiatric Association guidelines
    Lamitrogine as a first-line treatment for acute depression in bipolar disorder as well as a maintenance therapy
  • 15. Approach to the Patient WithBipolar Depression
    Is the patient already in treatment with amood stabilizer?
    Yes
    Then optimize the dose of the mood stabilizer
    Then add antidepressant
    No
    Then …
    APA Practice Guidelines
    Am J Psychiatry. 2002;159(4)supplement.
  • 16. Approach to the Patient with Bipolar DepressionThen...
    For less severely ill patients
    initiate lithium or lamotrigine
    For more severely ill patients
    initiate lithium and an antidepressant
    For those with psychosis or at high suicide risk
    add antipsychotic
    ECT
    APA Practice Guidelines
    Am J Psychiatry. 2002;159(4)supplement.
  • 17. Adverse Reaction
    Most common adverse reactions (incidence ≥10%) in adult epilepsy clinical studies were dizziness, headache, diplopia, ataxia, nausea, blurred vision, somnolence, rhinitis, and rash.
  • 18. Adverse Reaction
    Additional adverse reactions (incidence ≥10%) reported in children in epilepsy clinical studies included vomiting, infection, fever, accidental injury, pharyngitis, abdominal pain, and tremor.
  • 19. Adverse Reaction
    Most common adverse reactions (incidence >5%) in adult bipolar clinical studies were nausea, insomnia, somnolence, back pain, fatigue, rash, rhinitis, abdominal pain, and xerostomia.
  • 20. Black box: WARNING: SERIOUS SKIN RASHES
    Cases of life-threatening serious rashes, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and/or rash-related death, have been caused by LAITROGINE. The rate of serious rash is greater in pediatric patients than in adults. Additional factors that may increase the risk of rash include :
    - coadministration with Valproate
    -exceeding recommended initial dose .
    -exceeding recommended dose escalation .
    Benign rashes are also caused by LAMITROGINE; however, it is not possible to predict which rashes will prove to be serious or life threatening. LAMITROGINE should be discontinued at the first sign of rash, unless the rash is clearly not drug related.
  • 21. Risk factors
    Existing medical conditions. Viral infections, , human immunodeficiency virus (HIV) and systemic lupus erythematosus .
    Genetics. Carrying a gene called HLA-B12 is more susceptible to Stevens-Johnson syndrome
  • 22. Causes of Stevens-Johnson syndrome
    Medication causes
    Anti-gout medications, such as allopurinol
    Nonsteroidal anti-inflammatory drugs .
    Anticonvulsants.
  • 23. Causes of Stevens-Johnson syndrome
    Infectious causes
    Herpes (herpes simplex or herpes zoster)
    Influenza
    HIV
    Diphtheria
    Typhoid
    Hepatitis
    Other causes physical stimuli, such as radiation therapy or ultraviolet light.
  • 24. Signs and symptoms of Stevens-Johnson syndrome include
    Facial swelling
    Tongue swelling
    Skin pain
    A red or purple skin rash that spreads within hours to days over the skin and mucous membranes, mouth, nose and eyes
  • 25. Stevens-Johnson syndrome
  • 26.
  • 27.
  • 28. Skin Rash
  • 29. Skin Rash
  • 30. Concomitant use of Lamitrogine and aripiperzole increases risk of Stevens-Johnson syndrome?
    Shen, Yu-Chiha b c; Chen, Shaw-Jia b; Lin, Chaucer C.H.a b c; Chen, Chia-Hsianga b c
    International Clinical Psychopharmacology:
    July 2007 - Volume 22 - Issue 4 - pp 247-248
    doi: 10.1097/01.yic.0000224789.21406.81
  • 31. RECENT MAJOR CHANGES
    Warnings and Precautions, Aseptic Meningitis 35 cases in children
    October 2010
  • 32. Drug interaction
    • Valproate increases Lamotrigine concentrations more than 2-fold.
    • 33. Carbamazepine, phenytoin, Phenobarbital, and primidone decrease Lamotrigine concentrations by approximately 40%.
    • 34. Oral estrogen-containing contraceptives and rifampin also decrease Lamotrigine concentrations by approximately 50%.
  • Dose
    Asmono or adjunctive therapy, dosage: 100-400mg/day (slow titration upwards); minimal side effects profile , thus better compliance
  • 35. Dosing of Lamitrogine in adults & adolescents (once daily nocte)
    Week Daily dose (mg)
    1 25
    2 25
    3 50
    4 50
    5 100
    6 200
    NB 50% dose with Valproate & 200% with Carbamazepine; caution if on birth control pills (increased during the active hormone days, but reduced during the off hormone days)
    Ref: Calabrese et al, J ClinPsychiat 2002, 63, 1012-1019
  • 36. Frequency
    Linear pharmacokinetics and a half-life of 24 hours allows a once-daily dosing; rapid absorption.
  • 37. Administration
    • Initiation/titration: start with 25 mg daily X 2 weeks then increase to 50mg X 2 weeks then increase to 100mg- faster titration has a higher incidence of serious rash
    • 38. If the patient stops the medication for 5 days or more have to start at 25mg again.
  • USE IN SPECIFIC POPULATIONS
    • Hepatic impairment: Dosage adjustments required.
    • 39. Lamotrigine seems to be safe in Pregnancy?
    • 40. . Reduced maintenance doses may be effective for patients with significant renal impairment
  • Hepatic failure
    No dosage adjustment is needed in patients with mild liver impairment.
    Initial, escalation, and maintenance doses should generally be reduced by approximately 25% in patients with moderate and severe liver impairment without ascites.
    and 50% in patients with severe liver impairment with ascites.
  • 41. Plasma Levels
    A therapeutic plasma concentration range has not been established for Lamotrigine. Dosing should be based on therapeutic response
  • 42. Tips for Using Lamotrigine
    Very slow titration reduces risk of rash (25 mg/day as starting dose; can increase to 50 mg/day at week three, 100 mg/day at week five, and 200 mg/day at week six)
    Risk of serious rash with Lamotrigine is under 1% and is comparable to risk with carbamazepine, phenytoin, and phenobarbital
  • 43. Tips for Using Lamotrigine
    To avoid unrelated rash
    Patients should not try new medications, bath products, or foods during the first three months of Lamotrigine treatment
    Patients should not start Lamotrigine within two weeks of viral infection, rash, or vaccination
  • 44. Summary of DSM-IV-TR Classification of Bipolar Disorders
    Bipolar DisorderNot OtherwiseSpecified
    Cyclothymic
    Bipolar II
    Bipolar I
    One or more major depressive episodes accompanied by at least one hypomanic episode
    FEMALE>MALE
    Bipolar features that do not meet criteria for any specific bipolar disorders
    At least 2 years of numerous periods of hypomanic and depressive symptoms*
    One or more manic or mixed episodes, usually accompanied by major depressive episodes
    MALE=FEMALE
    * Symptoms do not meet criteria for manic and depressive episodes.
    First, ed. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000:345-428.
  • 45. Bipolar Depression
    50% of first bipolar episodes are depressive episodes
    Depressive episodes in bipolar disorder are associated with considerable morbidity and mortality
    Bipolar depressive episodes have a chronic course
    Goodwin FK and Jamison KR. Manic Depressive Illnessn
  • 46. Bipolar Depression
    80% of patients exhibit significant suicidality
    60% of patients with dysphoric mania exhibit suicidality
    Depressive episodes dominate course of bipolar disorder (twice the amount of time as in mania)
    25-30% of patients initially diagnosed with unipolar depression subsequently have a manic or hypomanic episode
    Goodwin FK and Jamison KR. Manic Depressive Illnessn
  • 47. Bipolar Disorder
    > 50% alcohol and/or other substance abuse
    About 50% attempt suicide
    About 15% succeed
    1Cookson J. Br J Psychiatry. 2001;178(suppl. 41): s148–s156.
    2Strakowski SM, et al. Expert Opin. Pharmacother. 2003;4:751-760.
  • 48. Predictors of Suicide in Bipolar Disorder
    High Impulsivity
    Alcohol and Substance Abuse
    DEPRESSION and MIXED Episodes
    History of Abuse in Childhood
    Exacerbated by incorrect treatment
    Akiskal. J Clin Psychopharmacol. 1996;16(suppl 1):4S-14S.
  • 49. Treatment Challenges in Bipolar Disorder
    Often unrecognized
    Often untreated
    Often misdiagnosed
    Often inadequately treated
    Exacerbated by incorrect treatment
    Akiskal. J Clin Psychopharmacol. 1996;16(suppl 1):4S-14S.
  • 50. Texas Implementation of Medication Algorithms initiative that made specific recommendations for patients presenting with hypomanic, manic, mixed episodes, or depressive episodes.
    TIMA
  • 51. Stage 1: Monotherapy* 1ALithium, valproate, atypicals excluding olanzapine and clozapine
    Nonresponse:Try alternate monotherapy
    Stage 2: Two-drug combination*Lithium, valproate, atypical antipsychoticChoose 2 (not 2 atypicals, not aripiprazole or clozapine)
    Partial response or nonresponse:Further medical consult or referralfor other treatment options
    Partial response
    TIMA Algorithm for Treatment of Acute Manic Episodes
    1B: Olanzapine†or carbamazepine†
    Response:Continue with therapy
    Response:Continue with therapy
    *Use targeted adjunctive treatment as necessary before moving to next stage. Agitation/Aggression─clonidine, sedatives; Insomnia─hypnotics; Anxiety─benzodiazepines, gabapentin.
    †All agents in Stage 1A and 1B are indicated for acute mania associated with bipolar I disorder. Safety and other concerns led to placement of olanzapine and carbamazepine as alternate first-stage choices.
    Suppes T, et al. J Clin Psychiatry. 2005;66:870-886.
  • 52. TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 1–3)
    Response: Continue with therapy
    Response: Continue with therapy
    Partial response or nonresponse
    Partial response or nonresponsive
    Taking no antimanic, with history of severe and/or recent mania
    Taking no antimanic, without history of severe and/or recent mania
    Taking otherantimanic
    Taking Li
    Increase to ≥ 0.8 mEq/L
    (continue)
    Stage 1
    Antimanic + LTG
    LTG
    Stage 2
    OFCaor QTPa
    Stage 3
    Combination from Li, LTG, QTP, or OFC
    aNote safety issue described in reference listed below (ie, olanzapine is associated with weight gain, quetiapine is associated with sedation and somnolence).
    Li = lithium; LTG = lamotrigine; OFC = olanzapine-fluoxetine combination; QTP = quetiapine.
    Suppes T, et al. J Clin Psychiatry. 2005;66:870-886.
  • 53. Response: Continue with therapy
    Response: Continue with therapy
    Partial response or nonresponse
    Partial response or nonresponse
    TIMA Bipolar: Treatment of Acute Depressive Episodes (Stages 4–5)
    Stage 4
    Li,LTGb, OFC, VPA, or CBZ + SSRIc, BUP, or VEN or ECT
    or QTP*
    Stage 5
    MAOIs, tricyclics, pramipexole, other AAPsa, OXC, other combinations of drugs at stages, inositol, stimulants, thyroid
    aNote safety issue described in reference listed below (ie, olanzapine is associated with weight gain, quetiapine is associated with sedation and somnolence).
    bLamotrigine has limited antimanic efficacy and, in combination with an antidepressant, may require the addition of an antimanic. cSSRIs include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and fluvoxamine.
    *Evidence supported by randomized controlled clinical trials with large effect sizes.
    AAP = atypical antipsychotic; BUP = bupropion; CBZ = carbamazepine; CONT = continuation; ECT = electroconvulsive therapy; Li = lithium; LTG = lamotrigine; MAOI = monoamine oxidase inhibitor; OFC = olanzapine-fluoxetine combination; OXC = oxcarbazepine; QTP = quetiapine; SSRI = selective serotonin reuptake inhibitor; VEN = venlafaxine; VPA = valproate.
    Suppes T, et al. J Clin Psychiatry. 2005;66:870-886.
  • 54. Evidence-based guidelines for treating
    bipolar disorder: revised second edition
    recommendations
    from the British Association for Psychopharmacology
    J Psychopharmacology 2009 23: 346 originally published online 27 March 2009
  • 55. The patient on no treatmentAcute depressive episode
    Choice of an initial treatment
    • For patients not already on long-term treatment for bipolar disorder Where an early treatment effect is desirable, consider
    quetiapine .
    • Consider initial treatment with Lamotrigine, with the necessary dose titration .
    • 56. Treatment with an antidepressant (e.g. selective serotonin
    reuptake inhibitor (SSRI) and an anti-manic agent (e.g. lithium,
    Valproate or an antipsychotic) together may be considered
    for patients with a history of mania
  • 57.
    • Antidepressant Monotherapy
    • 58. It is not recommended for such patients because of the increased risk of switch to mania , and should be used with caution in patients with a history of hypomania .
    • 59. If not already on an antipsychotic, consider adding an antipsychotic when patients have psychotic symptoms .
    • 60. Consider ECT for patients with high suicidal risk, psychosis, severe depression during pregnancy or life-threatening inanition
  • Simplifying pre-existing Polypharmacy
    • which may change seizure thresholds.
    • 61. When depressive symptoms are less severe, lithium or possibly Valproate may be considered .
  • Antidepressants
    Clinicians and patients should be aware of the risk of hypomania or rapid cycling in patients with bipolar-II or bipolar spectrum disorder treated with antidepressants alone
  • 62. Psychotherapy
    Consider interpersonal therapy, cognitive behavior therapy or family-focused therapy (FFT) when available since these may shorten the acute episode
  • 63. Depressive episode while on long-term
    • treatment Ensure adequate doses of medicines and that serum levels of lithium are within the therapeutic range .
    • 64. Address current stressors, if any
    • Ensure current choice of long-term treatments is likely to protect the patient from manic relapse (e.g. lithium, CBZ, Valproate, antipsychotic)
    • If the patient fails to respond to optimization of long-term treatment, and especially if depressive symptoms are significant, initiate treatment as above or consider augmentation or change of treatment .
    see Next-step treatments following inadequate treatment response to an antidepressant below
  • 65. Choice of antidepressant
    The limited evidence supports the
    modest efficacy of antidepressants such as the SSRIs (specifically fluoxetine) in bipolar disorder . However, antidepressants should not be uncritically employed as first-line medicines given continuing doubts about relative efficacy and their potential to destabilize mood
  • 66. Prevention of new episodes
    • Consider long-term treatment following a single severe manic episode
    (i.e. diagnosis of bipolar-I disorder).
    • the natural history of the illness implies that preventing early relapse may lead to a more benign illness course
  • Long-term treatment
    • Options for Long-term agents are often called mood stabilizers.
    • 67. An ideal mood stabilizer would prevent relapse to either pole of the illness.
    • 68. The available medicines are probably more often effective against one pole than the other
  • Long-term treatment
    • lithium specifically, is associated with a reduced risk of suicide in bipolar patients .
    • 69. Aripiperzole prevents manic relapse .
    • 70. CBZ is less effective than lithium , but may sometimes be employed as Monotherapy if lithium is ineffective and especially in patients who do not show the classical pattern of episodic euphoric mania
    • Oxcarbazepine for its low potential for drug interaction.
    • 71. Lamotrigine prevents depressive more than manic relapse.
    • 72. Olanzapine prevents manic more than depressive relapse.
    • 73. Quetiapine prevents both manic and depressive relapses.
    • 74. Valproate prevents manic more than depressive relapses
  • Combination treatment
    • When the burden of disease is mania, it may be logical to combine predominantly anti-manic agents (e.g. lithium, valproate, an antipsychotic)
    • 75. When the burden is depressive, Lamitrogine or quetiapine may be more appropriate
    • 76. In bipolar-I disorder,lamotrigine may usually require combination with an anti-manic long-term agent
  • The role of antidepressants in long-term treatment
    It is not established by controlled trials, but they appear to be used effectively in
    a small minority of patients in the long term
  • 77. Lamitrogine:Efficacy in Bipolar Disorder
    Placebo controlled 18-month trials of Lamotrigine and lithium – pooled analysis
    8-16 week open label treatment with Lamotrigine or lithium before randomization:
    N = 191 for placebo
    N = 280 for Lamotrigine (100-400 mgs/d)
    N = 167 for lithium (0.8-1.1 mEq/L)
    18-month maintenance treatment phase
    Both Lamotrigine and lithium superior toplacebo in preventing any mood episode
    Goodwin GM, et al;J Clin Psych 2004 Mar;65(3):432-441
    Bowden CL, et al;Arch Gen Psych 2003 Apr;60(4):392-400
    Calabrese JR, et al;J Clin Psych 2003 Sep;64(9):1013-1024
  • 78. Lamotrigine for treatment of bipolar depression: independent meta-analysis and meta-regression of individual patient data from five randomized trials
    John R. Geddes Joseph R. CalabreseGuy M. Goodwin
    The British Journal of Psychiatry (2009) 194: 4-9. doi: 10.1192/bjp.bp.107.048504© 2009 The Royal College of Psychiatrists
  • 79. Background
    There is uncertainty about the efficacy of Lamotrigine in bipolardepressive episodes
    Aims
    To synthesize the evidence for the efficacy of Lamotrigine inbipolar depressive episodes
    Method
    Systematic review and meta-analysis of individual patient datafrom randomized controlled trials comparing Lamotrigine withplacebo.
  • 80. Results
    Individual data from 1072 participants from five randomisedcontrolled trials were obtained. More individuals treated withlamotrigine than placebo responded to treatment on both theHamilton Rating Scale for Depression (HRSD) (relative risk(RR)=1.27, 95% CI 1.09–1.47, P=0.002) and Montgomery–ÅsbergDepression Rating Scale (MADRS) (RR=1.22, 95% CI 1.06–1.41,P=0.005). There was an interaction (P=0.04) by baseline severityof depression: lamotrigine was superior to placebo in peoplewith HRSD score >24 (RR=1.47, 95% CI 1.16–1.87, P=0.001)but not in people with HRSD score  24 (RR=1.07, 95% CI 0.90–1.27,P=0.445).
    Results
    Individual data from 1072 participants from five randomizedcontrolled trials were obtained. More individuals treated withLamotrigine than placebo responded to treatment on both theHamilton Rating Scale for Depression (HRSD) (relative risk(RR)=1.27, 95% CI 1.09–1.47, P=0.002) and Montgomery–ÅsbergDepression Rating Scale (MADRS) (RR=1.22, 95% CI 1.06–1.41,P=0.005).
  • 81. There was an interaction (P=0.04) by baseline severityof depression:lamotriginewas superior to placebo in peoplewith HRSD score >24 (RR=1.47, 95% CI 1.16–1.87, P=0.001)but not in people with HRSD score 24 (RR=1.07, 95% CI 0.90–1.27,P=0.445).
  • 82. Conclusions
    There is consistent evidence that Lamitrogine has a beneficialeffect on depressive symptoms in the depressed phase of bipolardisorder. The overall pool effect was modest, although theadvantage over placebo was larger in more severely depressedparticipants
  • 83.
  • 84. Switch to mania
    “Definite” switch involves fulfilling DSM-IV syndromic criteria for a manic, hypomanic, or mixed episode for at least 2 days, within 8 weeks of antidepressant introduction.
    75
  • 85. Switch to mania
    Recent literature suggests that the emergence of mania or hypomania can be reasonably attributed to antidepressant use in no more than 10% to 25% of patients with bipolar disorder
  • 86. Switch to mania
    “Likely” switches call for at least 2 DSM-IV mania or hypomania symptoms plus a Young Mania Rating Scale (YMRS) score >12, occurring for at least 2 days, within 12 weeks of antidepressant introduction.
    77
  • 87. Switch to mania
    True antidepressant-induced polarity switches persist even after the medication is discontinued
    78
  • 88. Switch to mania
    The largest dataset on this topic—the randomized controlled data from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)— found that the risk for treatment-emergent manic switch with paroxetine or bupropion was almost identical (about 10%) with or without an FDA-approved antimanic agent.
    79
  • 89. Switch to mania
    The largest dataset on this topic—the randomized controlled data from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)— found that the risk for treatment-emergent manic switch with paroxetine or bupropion was almost identical (about 10%) with or without an FDA-approved antimanic agent.
    80
  • 90. Schneck CD, Miklowitz DJ, Miyahara S, et al. The prospective course of rapid-cycling bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2008;165:370-377
    The use of antidepressants may increase a patient’s risk of rapid-cycling bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) included 1742 patients treated with a variety of approved medications for bipolar I and bipolar II disorder, and 32% reported having rapid-cycling at baseline. After 2 years of treatment, 5% still had rapid-cycling bipolar disorder. Those who were treated with an antidepressant were 3.8 times more likely to have rapid-cycling bipolar disorder.
  • 91. The Evidence for Lamitrogine in Bipolar Depression
    • Among antiepileptic drugs, clinical data favor lamotrigine as
    first-line treatment for acute bipolar depression1
    • The first open study in bipolar depressed patients reported symptomatic improvement in 72% of patients by end of 4 weeks, with 63% reported in remission by 6 weeks2
    • 92. Lamotrigine has demonstrated efficacy and safety in a
    multicenter double-blinded, placebo-controlled study of 195
    outpatients with bipolar I disorder, depressed3
    1. Muzina DJ, et al. Acta Psychiatr Scand. 2005;111(suppl 426):21-28.
    2. Kusumaker V, Yatham L. Psychiatry Res. 1997;72:145-148.
    3. Calabrese JR, et al. J Clin Psychiatry. 1999;60:79-88.
  • 93. Antidepressants for acute treatment of bipolar depression: A systematic review and meta-analysis
    JOURNAL OFCLINICAL PSYCHIATRY
    M.Sidor &G.MacQueen --October 2010
    Conclusion: although antidepressants were found to be safe for the acute treatment of bipolar depression ,their lack of efficacy may limit their clinical utility. further high quality studies are required to address the existing limitations in the literature.
  • 94. Altshuler L, Suppes T, Black D, et al. Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up. Am J Psychiatry. 2003;160:1252-1262
    Guidelines state that patients with bipolar depression who are treated with an antidepressant should discontinue therapy within 3 to 6 months after achieving remission. However, discontinuation of antidepressants has been shown to cause depressive relapse in these patients.
  • 95. Bipolar Disorder: Summary of Efficacy Evidence from RCTs
    Acute Mania
    MonoCombo
    AcuteDepression
    Maintenance
    Drug
  • 96. 0
    0
    -5
    -5
    -10
    -10
    -15
    -15
    -20
    -20
    0
    1
    2
    3
    4
    5
    6
    7
    0
    1
    2
    3
    4
    5
    6
    7
    Week
    Week
    Lamotrigine in Acute Treatment of Bipolar Depression
    LTG 50 mg/day (n = 64)
    LTG 200 mg/day (n = 63)
    Placebo (n = 65)
    LOCF
    Observed
    Change From Baseline of MADRS
    *



    *










    * P<0.1; †P<0.05. LOCF = last-observation-carried-forward.
    Calabrese et al. J Clin Psychiatry. 1999;60:79-88.
  • 97. Time to Intervention for a Mood Episode
    Lamotrigine vs Lithium vs Placebo
    LTG v. PBO, p < 0.001
    Li v. PBO, p < 0.001
    LTG v. Li, p = 0.629
    18 Mon.
    12 Mon.
    Index Manic or Depressed
    Goodwin et al., 2003 submitted
  • 98. Median = 13 weeks
    Lamotrigine vs Lithium vs Placebo: Relapse Prevention, Maintenance Therapy
    1
    Li vs PBO, P = 0.029
    LTG vs PBO, P = 0.029
    LTG vs Li, P = 0.915
    0.9
    0.8
    0.7
    Median = 24 weeks
    0.6
    Median = 29 weeks
    Survival Estimate
    0.5
    Li (n = 46)
    0.4
    LTG (n = 59)
    0.3
    PBO (n = 70)
    0.2
    0.1
    0
    60
    70
    0
    10
    20
    30
    40
    50
    LTG = lamotrigine 100 to 400 mg daily
    Li = lithium 0.8–1.1 mEq/L
    PBO = placebo
    Week
    Time to Intervention for a Mood Episode
    Bowden CL, et al. Arch Gen Psychiatry. 2003;60:392-400.
  • 99. Summary
    Lamotrigine is well established antiepileptic
    Lamotrigine is the second approved drug by FDA for the treatment of B.A.D Type 1.
    It is useful in the management of bipolar disorder specially the prevention of depressive episodes.
    It has the potential of helping unipolar depression.
  • 100. Summary
    Skin rash does not mean always Stevens-Johnson syndrome .
    Drug interaction is very important .
  • 101. THANK YOU
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