Aripiprazole mania

Pharmacotherapy is the cornerstone of acute and maintenance treatment of bipolar disorder. Mood-stabilizing drugs are the usual first-choice treatments and include lithium, divalproex, carbamazepine, and lamotrigine. Atypical antipsychotics other than clozapine are also approved for treatment of acute mania. Lithium, lamotrigine, olanzapine, and aripiprazole are approved for maintenance therapy. Drugs used with less research support and without Food and Drug Administration (FDA) approval include topiramate and oxcarbazepine. Benzodiazepines are used adjunctively for mania. 

Sprinkle capsule 15, 25 mg Atypical Antipsychotics FDA approved for use in bipolar disorder Aripiprazole Abilify Tablets 5, 10, 15, Dosage should be slowly increased to minimize adverse effects (e.g., 25 mg at bedtime for 1 week, then 25-50 mg/day increments at weekly intervals) 10-30 mg/day once daily acute treatment of mania or mixed episodes due to lack of efficacy used as an adjunctive agent with established mood stabilizers Use as monotherapy or in... 

Olanzapine Zyprexa 20, 30 mg Tablets 2.5, 5, 7.5, 10, 5-20 mg/day in 1 or 2 doses combination with lithium or valproate for the acute treatment of mania or mixed states for bipolar I disorder. Olanzapine and aripiprazole are approved for relapse prevention as well as for acute therapy... 

Conventional antipsychotic drugs such as chlorpromazine and haloperidol have long been used in the treatment of acute mania. More recently, atypical antipsychotic drugs including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasi-done have been approved for the treatment of bipolar mania or mixed mood episodes as monotherapy or in combination with mood-stabilizing drugs.25 Aripiprazole and olanzapine are also approved for maintenance therapy. The combination of olanzapine and fluoxetine is approved for treatment of bipolar depression. Quetiapine is approved for treatment of... 

Lithium, divalproex sodium (valproate), aripiprazole, olanzapine, que-tiapine, risperidone, and ziprasidone are currently approved by the FDA for treatment of acute mania in bipolar disorder. Lithium, olanzapine, and lamotrigine are approved for maintenance treatment of bipolar disorder. Quetiapine is the only antipsychotic that is FDA approved for bipolar depression. 

Quetiapine (Seroquel). Another atypical antipsychotic, quetiapine has also been approved by the FDA for the treatment of acute mania. It is usually administered twice daily at doses of 150-750mg/day. Like its counterparts, quetiapine is a well-tolerated medication. Its common side effects are drowsiness, dizziness, and headache. It causes less weight gain than olanzapine or clozapine but more than ziprasidone or aripiprazole. Quetiapine also does not cause agranulocytosis nor does it increase the risk of seizures. It can occasionally cause mild changes in liver function tests, but these usually return to normal even if the patient continues taking quetiapine. 

Aripiprazole (Abilify). Aripiprazole is indicated for the treatment of acute mania and for maintenance therapy. It is dosed at 5-30mg/day. Aripiprazole is well tolerated with the most common side effects being headache, agitation, anxiety, insomnia, and nausea. 

Choice of a Mood Stabilizer. With the advance of atypical antipsychotics and an ever-expanding list of anticonvulsants, the number of medications reported to treat acute mania and hypomania continues to grow. In fact, all of the atypical antipsychotics, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole have FDA approval for the treatment of acute mania. Long-term protection against future episodes of illness has also been demonstrated with several of these agents, which can influence the choice of initial therapy. 

Maintenance While it is generally agreed that treatment beyond an acute response in mania is desirable, there are no data to support the use of aripiprazole in longer-term treatment (ie, beyond 3 weeks). 

Another group of mood-stabilizing drugs that are also anticonvulsant agents have become more widely used than lithium. These include carbamazepine and valproic acid for the treatment of acute mania and for prevention of its recurrence. Lamotrigine is approved for prevention of recurrence. Gabapentin, oxcarbazepine, and topiramate are sometimes used to treat bipolar disorder but are not approved by FDA for this indication. Aripiprazole, chlorpromazine, olanzapine, quetiapine, risperidone, and ziprasidone are approved by FDA for the treatment of manic phase of bipolar disorder. Olanzapine plus fluoxetine in combination and quetiapine are approved for the treatment of bipolar depression. 

Until recently, lithium carbonate was the universally preferred treatment for bipolar disorder, especially in the manic phase. With the approval of valproate, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone for this indication, a smaller percentage of bipolar patients now receive lithium. This trend is reinforced by the slow onset of action of lithium, which has often been supplemented with concurrent use of antipsychotic drugs or potent benzodiazepines in severely manic patients. The overall success rate for achieving remission from the manic phase of bipolar disorder can be as high as 80% but lower among patients who require hospitalization. A similar situation applies to maintenance treatment, which is about 60% effective overall but less in severely ill patients. These considerations have led to increased use of combined treatment in severe cases. After mania is controlled, the antipsychotic drug may be stopped and benzodiazepines and lithium continued as maintenance therapy. 

In 142 adult patients who took aripiprazole (mean final daily dose 16 mg, 0.20 mg/kg) for psychotic, major affective, or other disorders, adverse effects occurred in 16, were three times more likely among women, and most often involved moderate behavioral activation or nausea, with no new episodes of mania (4). 

Although presently only lithium, valproic acid/divalproex, and several atypical antipsychotics have been approved by the FDA as treatments for acute mania, clinicians prescribe a number of other medications as well for patients in the manic phase (Table 3.20). The strength of the data justifying their use varies, with the strongest evidence occurring with lithium and followed by atypical antipsychotics (aripiprazole, olanzapine, etc.). 

Aripiprazole, olanzapine, quetiapine , risperidone, and ziprasidone are effective as monotherapy or as add-on therapy to lithium or valproate for acute mania. Prophylactic use of antipsychotics can he needed for some patients with recurrent mania or mixed states, hut the risks versus benefits must be weighed in view of long-term side effects (e.g., obesity, type 2 diabetes, hyperlipidemia, hyperprolactinemia, cardiac disease, and tardive dyskinesia). 

Olanzapine, quetiapine, and risperidone are preferred alternative atypicals aripiprazole and ziprasidone are newer agents and may initially cause akathisia-like reactions clozapine is usually reserved for treatment-resistant mania or mixed states. 

Several modem, better-tolerated antipsychotic agents (olanzapine, quetiapine, and risperidone) have recently received FDA approval for use in acute mania. There is also evidence of antimanic efficacy for aripiprazole and ziprasidone. Olanzapine is FDA-approved for its long-term effectiveness in bipolar disorder 1. Other atypical antipsychotic drugs are under investigation for long-term prophylactic treatment of bipolar disorder. 

Vieta E, Owen R, Baudelet C, McQuade RD, Sanchez R, Marcus RN. Assessment of safety, tolerability and effectiveness of adjunctive aripiprazole to lith-ium/valproate in bipolar mania a 46-week, open-label extension following a 6 week double-blind study. Curr Med Res Opin 2010 26(6) 1485-96. 

Antipsychotic drugs are more often used in the treatment of bipolar illness. Lithium was equivalent to aripiprazole, and both were superior to placebo, in a 3-week, double-blind, randomized, placebo-controlled study of acutely manic patients [5 ]. The improvement was maintained for an additional 9 weeks (a total of 12 weeks), with a 12.7 point drop in Young Mania Rating Scale score for lithium and a 14.5 point drop for aripiprazole. The most common adverse events with aripiprazole were headache, nausea, akathisia, sedation, and constipation and with lithium nausea, headache, constipation, and tremor. 

Study Group. Aripiprazole monotherapy in the treatment of acute bipolar I mania a randomized, double-blind, placebo- and lithium-controlled study. J Affect Disord 2009 112(1-3) 36-49. 

Observational studies In a 6-week, prospective, unrandomized, open study in 20 patients with acute bipolar depression, aripiprazole up to a maximum of 30 mg/ day improved Montgomery-Asberg Depression Rating Scale (MADRS) and Mania Rating Scale (MRS) scores significantly [64 ]. The most fi-equent adverse reactions were nausea and akathisia two patients withdrew because of akathisia. 

Vieta E, T joen C, McQuade RD, Carson Jr. WH, Marcus RN, Sanchez R, Owen R, Nameche L. Efficacy of adjunctive aripiprazole to either valproate or lithium in bipolar mania patients partially nonresponsive to valproate/lithium monotherapy a placebo-controlled study. Am J Psychiatry 2008 165(10) 1316-25. 

Antipsychotics are also used for mood stabilisation in acute mania or BPAD prophylaxis (e.g. aripiprazole, olanzapine, risperidone, quetiapine). They require the usual antipsychotic monitoring. Some offer IM options and none need drug levels, which can help when people are acutely uncooperative or chaotic. 

Aripiprazole. Adult oral dose 10-30 mg daily in single dose (schizophrenia, mania), 5.25-15 mg by intramuscular injection for control of agitation. 

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