There can be variation in the licensing of
different medicines containing the same drug.
Modified-release tablet
CAUTIONARY AND ADVISORY LABELS 2, 25
▶Intuniv (Shire Pharmaceuticals Ltd) A
Guanfacine (as Guanfacine hydrochloride) 1 mg Intuniv 1mg
modified-release tablets | 28 tablet P £56.00 DT = £56.00
Guanfacine (as Guanfacine hydrochloride) 2 mg Intuniv 2mg
modified-release tablets | 28 tablet P £58.52 DT = £58.52
Guanfacine (as Guanfacine hydrochloride) 3 mg Intuniv 3mg
modified-release tablets | 28 tablet P £65.52 DT = £65.52
Guanfacine (as Guanfacine hydrochloride) 4 mg Intuniv 4mg
modified-release tablets | 28 tablet P £76.16 DT = £76.16
3.3 Bipolar disorder and mania
Mania and hypomania
Overview
Antimanic drugs are used to control acute attacks and to
prevent recurrence of episodes of mania or hypomania.
An antidepressant drug may also be required for the
treatment of co-existing depression, but should be avoided
in patients with rapid-cycling bipolar disorder, a recent
history of hypomania, or with rapid mood fluctuations.
Benzodiazepines
Use of benzodiazepines (such as lorazepam p. 355) may be
helpful in the initial stages of treatment for behavioural
disturbance or agitation; they should not be used for long
periods because of the risk of dependence.
Antipsychotic drugs
Antipsychotic drugs (normally olanzapine p. 416, quetiapine
p. 419, or risperidone p. 421) are useful in acute episodes of
mania and hypomania; if the response to antipsychotic drugs
is inadequate, lithium or valproate may be added. An
antipsychotic drug may be used concomitantly with lithium
or valproate in the initial treatment of severe acute mania.
See Important safety information, Conception and
contraception, and Pregnancy in the valproic acid p. 372 and
sodium valproate p. 344 monographs.
Olanzapine can be used for the long-term management of
bipolar disorder in patients whose manic episode responded
to olanzapine therapy. It can be given either as
monotherapy, or in combination with lithium or valproate if
the patient has frequent relapses or continuing functional
impairment.
Asenapine p. 373, a second-generation antipsychotic, is
licensed for the treatment of moderate to severe manic
episodes associated with bipolar disorder.
When discontinuing antipsychotics, the dose should be
reduced gradually over at least 4 weeks if the patient is
continuing with other antimanic drugs; if the patient is not
continuing with other antimanic drugs or if there is a history
of manic relapse, a withdrawal period of up to 3 months
should be considered.
Carbamazepine
Carbamazepine p. 327 may be used under specialist
supervision for the prophylaxis of bipolar disorder (manic-
depressive disorder) in patients unresponsive to a
combination of other prophylactic drugs; it is used in
patients with rapid-cycling manic-depressive illness (4 or
more affective episodes per year). The dose of
Nervous system
carbamazepine should not normally be increased if an acute
episode of mania occurs.
Valproate
Valproate (valproic acid (as the semisodium salt) and sodium
valproate) is used for the treatment of manic episodes
associated with bipolar disorder. It must be started and
supervised by a specialist experienced in managing bipolar
disorder. Valproate (valproic acid and sodium valproate) is
also used for the prophylaxis of bipolar disorder. Because of
its high teratogenic risk, valproate must not be used in
females of childbearing potential unless the conditions of
the Pregnancy Prevention Programme are met and
alternative treatments are ineffective or not tolerated.
Valproic acid and sodium valproate must not be used during
pregnancy in bipolar disorder. The benefit and risk of
valproate therapy should be carefully reconsidered at regular
treatment reviews. For further information, see Important
safety information, Conception and contraception, and
Pregnancy in the valproic acid and sodium valproate
monographs.
In patients with frequent relapse or continuing functional
impairment, consider switching therapy to lithium or
olanzapine, or adding lithium or olanzapine to valproate. If a
patient taking valproate experiences an acute episode of
mania that is not ameliorated by increasing the valproate
dose, consider concomitant therapy with olanzapine,
quetiapine, or risperidone.
Lithium
Lithium salts are used in the prophylaxis and treatment of
mania, hypomania and depression in bipolar disorder
(manic-depressive disorder), and in the prophylaxis and
treatment of recurrent unipolar depression. Lithium is also
used as concomitant therapy with antidepressant medication
in patients who have had an incomplete response to
treatment for acute bipolar depression and to augment other
antidepressants in patients with treatment-resistant
depression [unlicensed indication]. It is also licensed for the
treatment of aggressive or self-harming behaviour.
The decision to give prophylactic lithium requires
specialist advice, and must be based on careful consideration
of the likelihood of recurrence in the individual patient, and
the benefit of treatment weighed against the risks. The full
prophylactic effect of lithium may not occur for six to twelve
months after the initiation of therapy. Olanzapine or
valproate (given alone or as adjunctive therapy with lithium)
are alternative prophylactic treatments in patients who
experience frequent relapses or continued functional
impairment.
Other drugs used for Bipolar disorder and mania
Aripiprazole, p. 413. Chlorpromazine hydrochloride, p. 402.
Haloperidol, p. 404. Lamotrigine, p. 334. Paliperidone,
p. 418. Prochlorperazine, p. 407. Zuclopenthixol acetate,
p. 409
ANTIEPILEPTICS
PDF pages 393, 394
