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Table Reference Number
Table 5–3. Anticonvulsant dosages in bipolar illness
Table Reference Number

Note. CNS = central nervous system; ER = extended-release; FDA = U.S. Food and Drug Administration; GI = gastrointestinal; IR = immediate-release.

Valproate therapy: overview

Efficacy

Acute mania (FDA approved)

Bipolar prophylaxis (may be effective)

Mixed, rapid-cycling bipolar

Seizure disorders (FDA approved)

Side effects

Weight gain

Sedation

GI upset

Safety in overdose

Serious effects notable mostly at 20 times normal serum level. Symptoms include nausea, vomiting, CNS depression, and seizures. Manage with gastric lavage, forced emesis, and assisted ventilation.

Dosage and administration

Start IR formulation at 15 mg/kg/day and ER formulation at 25 mg/kg/day in divided doses, up to a maximum of 60 mg/kg. Achieve serum levels of 50–100 g/mL.

Discontinuation

Rapid discontinuation increases the risk of rapid relapse in bipolar disorder. Otherwise, discontinuation symptoms are uncommon.

Drug interactions

Drugs that valproate serum levels include:

 cimetidine

 erythromycin

 phenothiazines

 fluoxetine

 aspirin

 ibuprofen

Drugs that valproate serum levels include:

 rifampin

 carbamazepine

 phenobarbital

 ethosuximide

Table Reference Number
Table 5–4. Drug interactions of anticonvulsant mood stabilizers
Table Reference Number

Note. CNS = central nervous system; FDA = U.S. Food and Drug Administration; TCAs = tricyclic antidepressants; XR = extended-release.

Carbamazepine therapy: overview

Efficacy

Acute mania (FDA approved for Equetro only)

Mixed, rapid-cycling bipolar (not FDA approved)

Seizure disorders (FDA approved)

Side effects

Sedation

Dizziness

Fatigue and nausea

Ataxia

Safety in overdose

Serious symptoms may occur at 10–20 times normal serum levels. Symptoms include nausea, vomiting, CNS depression, respiratory depression, and seizures. Management includes gastric lavage, forced emesis, assisted ventilation.

Dosage and administration

For the XR form: 200 mg bid, to therapeutic range of 800–1,200 mg/day. Follow serum levels to 6–10 g/mL.

Discontinuation

Carbamazepine has not been associated with a withdrawal syndrome with rapid discontinuation. However, as with other mood stabilizers, rapid discontinuation is associated with an increased risk of rapid relapse. In bipolar patients, decrease dose over 6 months. In nonbipolar patients, dose may be decreased by 25% every 3 days.

Drug interactions

Drugs that may carbamazepine levels include: cimetidine, ciprofloxacin, diltiazem, fluoxetine, fluvoxamine, doxycycline, erythromycin, fluconazole, grapefruit juice, INH (isoniazid), ketoconazole, macrolide antibiotics (erythromycin, clarithromycin, troleandomycin), nefazodone, norfloxacin, prednisolone, propoxyphene, protease inhibitors (e.g., ritonavir), TCAs, valproate, verapamil, and warfarin

Drugs whose blood levels are by coadministration with carbamazepine include: atypical antipsychotics, benzodiazepines, doxycycline, ethosuximide, fentanyl, glucocorticoids, haloperidol, methadone, oral contraceptives, phenothiazines, phenytoin, sertraline, TCAs, and theophylline

Table Reference Number
Table 5–5. New anticonvulsants

References

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