Mood Stabilizers olanzapine

First, initiate and/or optimize mood-stabilizing medication lithium3 or valproate3 or atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone)... 

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. 

Mood-stabilizing drugs are considered the primary pharmacotherapy for relapse prevention. Olanzapine and aripiprazole are also approved for maintenance 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... 

First, optimize current mood stabilizer or initiate mood-stabilizing medication lithium,0 valproate,0 or carba-mazepine0 Consider adding a benzodiazepine (lorazepam or clonazepam) for short-term adjunctive treatment of agitation or insomnia if needed Alternative medication treatment options carbam-azepine0 if patient does not respond or tolerate, consider atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone) or oxcarbazepine. 

Higher initial doses of antipsychotics (e.g., 20 mg/day of olanzapine) are required for acute mania, but once mania is controlled (usually 7 to 28 days), the antipsychotic can be gradually tapered and discontinued, and the patient maintained on the mood stabilizer alone. 

Mood stabilizers (e.g., lithium, valproic acid, and carbamazepine) used as augmentation agents may improve labile affect and agitated behavior. A placebo-controlled trial supports fast symptom improvement when divalproex is combined with either olanzapine or risperidone. 

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. 

Chang, K.D., and Ketter, T.A. (2000) Mood stabilizer augmentation with olanzapine in acutely manic childten. J Child Adolesc Psychopharmacol 10 45—49. 

In the Expert Consensus survey (Rush and Frances, 2000), respondents were asked to rate which classes of medication may be helpful for treating patients with severe and persistent physical aggression and those who destroyed property. The atypical antipsychotics were rated most highly, followed by anticonvulsant/ mood stabilizer. These were followed (with much lower priority) by antidepressants and beta-blockers. Among the atypical antipsychotics, risperidone was rated most highly, followed by olanzapine others had much lower ratings. Divalproex or valproic acid and carbamazepine were rated highest of the mood stabi-... 

In fact, with more moderate-to-severe episodes, a mood stabilizer alone is usually insufficient, and initial treatment often requires a concurrent antipsychotic, preferably a novel agent. In these situations, we advocate using an initial lower-dose schedule (e.g., risperidone 1 to 4 mg/day olanzapine 2.5 to 10 mg/day). If primary mood stabilizers are ineffective or not tolerated, evidence indicates that monotherapy with agents such as olanzapine or risperidone may be effective. 

Recent case reports have suggested that atypical antipsychotics may also benefit patients with PTSD. For example, low doses of risperidone in combination with an antidepressant or mood stabilizer were reported effective for nightmares and flashbacks in patients with treatment-refractory PTSD ( 292). Both clozapine and olanzapine have also been reported to reduce PTSD symptoms in patients with a co-morbid psychotic disorder ( 293, 294). Finally, olanzapine added to fluoxetine resulted in significant improvement of hyperarousal symptoms in a patient with treatment-refractory PTSD caused by severe childhood physical and sexual abuse (295). 

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. 

Mood stabilizers, such as lithium, lamotrigine, and carba-mazepine, may be effective in treating glucocorticoid-induced mood symptoms. In an open trial, 12 patients with glucocorticoid-induced manic or mixed symptoms were treated with olanzapine 2.5 mg/day initially, increasing to a maximum of 20 mg/day 11 of the 12 patients had significant improvement (505). 

While there are no absolute contraindications to lithium, patients with advanced kidney disease or unstable fluid/ electrolyte balance may be more safely treated with an alternative mood stabilizer, such as carbamazepine, valproate, lamotrigine, or olanzapine. 

Olanzapine may be preferable to anticonvulsant mood stabilizers if treatment is required during pregnancy... 

Quantifying blood levels of those compounds for which assays are available is an easy and reliable method to ensure compliance and assess metabolic status. Reliable assays are currently available for compounds such as nortriptyline, clozapine, olanzapine, risperidone, and all the mood stabilizers. 

Lithium has unique properties as a treatment for manic depression, but it is by no means the only treatment. Other mood-stabilizing drugs are also prescribed for treatment of the manic phase of the disorder. These drugs are often anticonvulsants such as Depakote (valproate) or sometimes antipsychotic drugs such as Zyprexa (olanzapine). As these drugs are not traditionally thought of as antidepressants, they will not be discussed in detail. 

Because bipolar disorders are recurring illnesses, clients will often require an ongoing regimen of medication. There are various categories of psychotropic medications that are used in the treatment of bipolar disorders. This includes the SSRIs (discussed in chapter 4), which are generally used to treat depression and some types of anxiety, and the most recent addition Zyprexa (olanzapine), which is one of the newer antipsychotic medications (Portyansky, 2000). Of all of the medications that can be used, however, the most common are generally termed mood stabilizers (Dulcan, 1999) and include Lithium or other medications that fall within the anticonvulsant category. 

Clinical experience with various pharmacological regimens (mainly mood stabilizers) has suggested that a drug that is efficacious in one manifestation of mania is not necessarily the treatment of choice for the overall spectrum of manic states. Much progress have been made in the treatment of acute manic states, especially since the demonstrated efficacy of the second-generation antipsychotics (e.g. olanzapine, quetiapine, and risperidone) for the treatment of acute mania. However, treatment of acute manic states remains incomplete, and new treatment strategies are in continuous development. ... 

Blood levels clearly correlate with therapeutic response for a minority of the psychotropic drugs, including the antipsychotics haloperidol, clozapine, and olanzapine the tricyclic antidepressants and the mood stabilizer lithium. 

---