COMMENTARY

The Texas Implementation of Medication Algorithms on the Use of Anticonvulsants in Bipolar I Disorder

Trisha Suppes, MD, PhD; Dorothy Kelly, MA

May 05, 2006

Overview

It is only within the last 15 years that companies have begun to focus on the use of anticonvulsants in the treatment of bipolar disorder, and many new drugs have entered the market during that time. Although anticonvulsants have shown efficacy in the treatment of bipolar I disorder (BDI), only divalproex sodium and extended-release carbamazepine have received an indication for the treatment of acute mania, and to date, only lamotrigine has received an indication as a maintenance treatment of BDI. Despite this, many anticonvulsants are used "off-label" in the treatment of bipolar disorder, as helpful antimanic agents or adjunctive treatments. The Texas Implementation of Medication Algorithms (TIMA) includes anticonvulsants in its recommendations, as well as atypical antipsychotics, lithium, and other classes of medication.^[1] For the purposes of this discussion, we will focus on evidence and recommendations for the use of anticonvulsants, although other options at each stage will also be mentioned.

1 2 3 4 5 6

Next Section

Cite this: The Texas Implementation of Medication Algorithms on the Use of Anticonvulsants in Bipolar I Disorder - Medscape - May 05, 2006.

Table 1. Maintenance Treatment: Most Recent Episode Hypomanic/Manic/Mixed
Level I	Patients with frequent, recent, or severe mania	Lithium or valproate
	Patients without frequent, recent, or severe mania	Lithium, valproate, or lamotrigine
	Alternative	Olanzapine
Level II		Aripiprazole
Level III		Carbamazepine or clozapine
Level IV		Quetiapine, risperidone, or ziprasidone
Level V		Typical antipsychotics, oxcarbazepine, electroconvulsive therapy

Table 2. Maintenance Treatment: Most Recent Episode Depression
Level I	Patients with recent and/or severe history of mania	Lamotrigine combined with an antimanic agent
Level I	All other patients	Lamotrigine monotherapy
Level II		Lithium
Level III		Combination of an antimanic and antidepressant that has been effective in the past, including olanzapine-fluoxetine combinationa
Level IV		Valproate, carbamazepine, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone
Level V		Typical antipsychotics, oxcarbazepine, electroconvulsive therapy

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.