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3 authors, including:
Mark Taylor
Polash Shajahan
NHS Lanarkshire
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Abstract: Bipolar disorder is a common and serious illness usually requiring long term medication. We critically review the available
evidence surrounding the increasing use of quetiapine, a second generation antipsychotic, in both the acute and maintenance phases
of bipolar disorder. Large scale, randomized controlled data supports the use of quetiapine in both acute mania and acute bipolar
depression, as a safe and effective treatment and probably best used in combination with a traditional mood stabiliser such as lithium
or divalproex. Also, quetiapine monotherapy has been shown to be effective in bipolar depression. Two recently published studies also
confirm that quetiapine in combination with either lithium or divalproex adds value to the maintenance treatment of bipolar disorder in
terms of delaying relapse compared to either lithium or divalproex alone. Quetiapine is generally well tolerated, although further work
on long term weight gain and emergent diabetes would be helpful.
Keywords: quetiapine, bipolar disorder, lithium, divalproex
657
Taylor et al
Introduction
660
Mania
Mixed
Maintenance/
Relapse prevention/
Remission/
Euthymia
Depressed
Phase of bipolar
1st = Li mono
1st Cbz mono
(if Li not acceptable or
for BpDII)
1st = Lamot mono
(if stabilized on this)
1st = AD in combo
with an AP, Li or Valp
1st = Lamot
Nothing specified
SIGN (Scottish
Intercollegiate
Guidelines Network)
1st = AD (SSRI)
+ antimanic agent
1st Quet + non AP
antimanic agent
2nd = Switch AD to
mirt or Venlaf or add
Quet or Ol (if not on
AAP) 3rd =
NICE (National
Institute of Clinical
Excellence)
Table 1. Guideline recommendations for pharmacotherapy in the various phases of bipolar disorder.
1st = Li/Valp/AAP/Cbzl,o
1st = Li/Valp/Cbzm,o
2nd = Combination with a second
MS or AAPl,o,p
2nd = Change of MSl,o,q
2nd = Combination of 2 MS,
preferably anticonvulsant + Lim,o
3rd = Combination with a second
MS or AAPl,o
Taylor et al
Notes: Mono: Monotherapy; AAP, Atypical antipsychotic; AD, Antidepressant; AP, Antipsychotic; Arp, Aripriprizole; Bnz, Benzodiazepine; Cbz, Carbamazepine; Cloz, Clozapine; Dival,
Divalproex; IM, Intramuscular; Lamot, Lamotragine; Li, Lithium; MAOI, Monamine Oxidase Inhibitor; Mirt, Mirtzaepine; Olz, Olanzapine; Quet, Quetiapine; RC, Rapid cycling; Risp, Risperidone;
Rx, Treatment; SSRI, Selective serotonin re-uptake inhibitor; TCA, Tricyclic antidepressant; UP, Unipolar; Valp, Valproate; Venlaf, Venlafaxine.
a
Atypical antipsychotics should be considered because of their generally more favorable short-term adverse event profile and the increasing evidence of their efficacy as anti-manic agents.
b
For patients not already on long-term treatment for bipolar disorder.
c
For patients who suffer a manic/mixed/depressive episode while on long-term treatment.
d
For patients who suffer a depressive episode while on long-term treatment.
e
When mania is the burden of the illness.
f
When depression is the burden of the illness.
g
Not in women of child bearing potential.
h
Those not on anti-manic treatment.
I
Those on anti-manic treatment.
J
Moderate/severe depression.
K
Severe and/or psychotic depression.
l
Mild to moderate mania.
m
Severe mania.
n
Adjunctive treatment; + benzodiazepine, atypical antipsychotic or sleep deprivation.
o
Adjunctive treatment; + benzodiazepine or antipsychotic (preferably atypical).
p
Previous maintenance treatment successful, but no acute response.
q
Initial treatment and prior maintenance unsuccessful.
r
Bipolar I disorder without rapid cycling.
s
Bipolar I with rapid cycling.
t
Bipolar II without rapid cycling.
u
Bipolar II with rapid cycling.
v
Schizoaffective disorder (bipolar type).
w
Mania-dominant type.
x
Depression-dominant type.
y
Severe manias.
z
Prominent depressions.
aa
Schizo-dominant type.
bb
If not already on an antipsychotic.
Rapid cycling
661
Taylor et al
Table 2. Quetiapine monotherapy versus placebo (pbo) and active comparator in mania.
Authors
McIntyre etal10
Bowden etal11
Design
Setting
Europe; Asia
Duration
12 weeks
12 weeks
302
302
55:55:42
67:68:36
61:70:39
72:76:41
51:60:30
72:72:37
5:10:6
6.5:6:4
Yatham etal13
Yatham etal15
Design
Setting
Duration of study
3 weeks
6 weeks
402
211
64:54
67:59
56:42
57:50
58.5:43
76:59
6:4
6:2
662
Maintenance Pharmacotherapy
in Bipolar Disorder
Calabrese etal17
Thase etal18
Design
Setting
USA
USA
Duration
8 weeks
8 weeks
542
509
61:59
56:65.5
58:58:36
58:60:45
56:64:34
60:61:38.5
26:16:9
11:8:1
663
Taylor et al
Vieta etal25
Suppes etal24
Design
Setting
Worldwide
Duration
706
628
63:37
35:21
18.5:49
20:52
2.4:3
11.3:2.6
7.4:2
11.5:3.7
664
Conclusions
Taylor et al
Acknowledgment
Declaration of Interest
References
666
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