Bipolar disorder in pregnant women - Treatment of major depression.pdf

Publish in

Documents

219 views

Please download to get full document.

View again

of 14
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Share
Description
Bipolar disorder in pregnant women: Treatment of major depression http://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women... Official reprint from UpToDate® www.uptodate.com ©2013 UpToDate® Bipolar disorder in pregnant women: Treatment of major depression Author Victoria Hendrick, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Nov 16, 2013. INTR
Tags
Transcript
  Official reprint from UpToDatewww.uptodate.com ©2013 UpToDate Author  Victoria Hendrick, MD Section Editor  Paul Keck, MD Deputy Editor  David Solomon, MD Bipolar disorder in pregnant women: Treatment of major depressionDisclosures  All topics are updated as new evidence becomes available and our peer review processis complete. Literature review current through:  Oct 2013.| This topic last updated:  Nov 16, 2013. INTRODUCTION  — Medications are commonly used to treat pregnant patients, including those with bipolar major depression [1]. At least one prescription drug is taken by more than 60 percent of pregnant patients [2], and psychotropic drugs are taken by 21 to 33 percent [3,4].This topic discusses treatment of pregnant patients with bipolar major depression. Treatment of manic andhypomanic episodes during pregnancy, prenatal maintenance pharmacotherapy for bipolar disorder, the teratogenicand postnatal risks of pharmacotherapy for bipolar disorder, and the general treatment of bipolar major depressionare discussed separately. DEFINITION OF BIPOLAR DISORDER  — Bipolar disorder is characterized by episodes of mania (table 1),hypomania (table 2), and major depression (table 3) [5]. The subtypes of bipolar disorder include bipolar I and bipolar II. Patients with bipolar I disorder experience manic episodes, and nearly always experience major depressive and hypomanic episodes. Bipolar II disorder is marked by at least one hypomanic episode, at least onemajor depressive episode, and the absence of manic episodes. Additional information about the clinical featuresand diagnosis of bipolar disorder is discussed separately. (See Bipolar disorder in adults: Clinical features  and Bipolar disorder in adults: Assessment and diagnosis , section on 'Diagnosis'.) INDICATIONS  — Pharmacotherapy is indicated for pregnant patients with bipolar major depression that ischaracterized by [6]: GENERAL PRINCIPLES AND MANAGEMENT  — Bipolar mood episodes during pregnancy are usually treated byperinatal or general psychiatrists in collaboration with obstetricians and primary care clinicians [4,7-10].For pregnant patients with bipolar major depression, treatment is based upon randomized trials that excludedpregnant patients [11-14], as well as observational studies, birth registries, and clinical experience [15].  Additional information about the general principles and management of treating bipolar mood episodes duringpregnancy are discussed separately, as is the general treatment of bipolar major depression. (See Bipolar disorder in pregnant women: Treatment of mania and hypomania , section on 'Management' and Bipolar disorder in adults: Pharmacotherapy for acute depression .) Duration of individual drug trial  — We suggest treating pregnant patients with bipolar major depression for six toeight weeks before determining whether a specific drug is beneficial, based upon theduration of most randomized ®® (See Bipolar disorder in pregnant women: Treatment of mania and hypomania .)● (See Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy .)● (See Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy .)● (See Bipolar disorder in adults: Pharmacotherapy for acute depression .)● Suicidal or homicidal ideation or behavior ● Aggressive behavior ●Psychotic features (delusions or hallucinations)●Poor judgement that places the patient or others at imminent risk of being harmed●Moderate to severe impairment of social or occupational functioning● Bipolar disorder in pregnant women: Treatment of major depressionhttp://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women...1 de 1402/12/2013 04:41  trials (which excluded pregnant patients) [11-13,16]. Response is defined as stabilizing the patient’s safety andsubstantial improvement in the number, intensity, and frequency of symptoms. SELECTING TREATMENT  — Bipolar major depression during pregnancy is typically treated withpharmacotherapy because it is easier to administer, more widely available, and more acceptable to patients thanelectroconvulsive therapy (ECT). However, refractory patients may benefit from ECT. First line treatment  — For pregnant patients with bipolar major depression, we suggestlamotrigine as first linetreatment, based upon efficacy in a meta-analysis of randomized trials that excludedpregnant patients [14]. Up to40 to 50 percent of patients may respond (defined as stabilizing the patient’s safety and substantial improvement inthe number, intensity, and frequency of symptoms). In addition, the reproductive safety profile of lamotrigine isgenerally regarded as favorable [4,17,18]. The efficacy of lamotrigine andquetiapine appear to be comparable, but there is more experience using lamotrigine during pregnancy than quetiapine. In addition, there is moreevidence supporting the efficacy of lamotrigine compared withfluoxetine plusolanzapine or lamotrigine pluslithium, and prenatal treatment with monotherapy is preferable to treatment with drug combinations due to concerns aboutteratogenic effects.The efficacy of lamotrigine,quetiapine,fluoxetine plusolanzapine, and lamotrigine pluslithium; reproductive safety profile of these drugs; and the dose schedule, side effects (table 4 andtable 5) (including life-threatening skin rash), and pharmacology of lamotrigine are discussed separately. (See Bipolar disorder in adults:Pharmacotherapy for acute depression  and Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy  and Bipolar disorder in adults: Maintenance treatment , section on 'Lamotrigine' and Pharmacology of antiepileptic drugs , section on 'Lamotrigine'.) Treatment resistance  — For pregnant patients with bipolar major depression who do not respond tolamotrigineor cannot tolerate it, we suggestquetiapine [19], based upon randomized trials that excluded pregnant patients [20-23]. Up to 50 to 60 percent of patients may respond (defined as stabilizing the patient’s safety and substantialimprovement in the number, intensity, and frequency of symptoms). In addition, otherstudies suggest thatquetiapine is not associated with teratogenic effects [24], and use of quetiapine for bipolar major depression duringpregnancy is consistent with practice guidelines from the United Kingdom National Institute for Health and ClinicalExcellence [25,26]. There is more evidence supporting the efficacy of lamotrigine compared withfluoxetine plus olanzapine or lamotrigine pluslithium, and prenatal treatment with monotherapy is preferable to treatment with drug combinations due to concerns about teratogenic effects.We generally taper and discontinuelamotrigine at the same time thatquetiapine is started and titrated up. Lamotrigine is usually tapered by the same amount for each dose decrease over a one to two week period. As anexample, lamotrigine 200 mg per day is decreased by 50 mg per day every three to four days.Second-generation antipsychotics may cause metabolic complications (eg, hyperglycemia and obesity) that areassociated with risks to the mother and fetus [27,28]. These risks are discussed separately, as are monitoring of metabolic parameters in pregnant patients taking second-generation antipsychotics and the efficacy, dose,reproductive safety, pharmacology, and side effects of quetiapine. (See Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy , section on 'Metabolic complications' and Bipolar disorder in adults:Pharmacotherapy for acute depression  and Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy , section on 'Second-generation' and Second-generation antipsychotic medications:Pharmacology, administration, and comparative side effects , section on 'Quetiapine'.) Refractory patients  — Pregnant patients with bipolar major depression often do not respond to sequential trialsof lamotrigine andquetiapine. For these refractory patients, we suggest tapering and discontinuing quetiapine over  one to two weeks at the same time that another medication regimen is started and titrated up. (Response isdefined as stabilizing the safety of the patient and others, as well as substantial improvement in the number,intensity, and frequency of symptoms.) Quetiapine is generally tapered by the same amount for each dosedecrease. As an example, quetiapine 600 mg per day is decreased by 50 to 100 mg per day, every one to twodays.We suggest using the following treatments in sequence for pregnant patients with refractory bipolar major depression, based upon their efficacy in randomized trials (which excluded pregnant patients), reproductive safetyprofiles, and adverse effects. Although the benefit of fluoxetine plusolanzapine and the combination of lamotrigine Bipolar disorder in pregnant women: Treatment of major depressionhttp://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women...2 de 1402/12/2013 04:41  andlithium appear to be comparable, neither fluoxetine nor olanzapine appear to be associated with teratogeniceffects. By contrast, lithium is generally regarded as teratogenic [29-31]. The proportion of patients who respondto any of the following treatment regimens may be as high as approximately 50 percent, based upon trials innonpregnant patients [11,12].Fluoxetine  plus olanzapine – Fluoxetine plus olanzapine is efficacious for bipolar major depression innonpregnant patients [12,32]. However, second-generation antipsychotics, especially olanzapine, may causemetabolic complications (eg, hyperglycemia and obesity) that are associated with risks to the mother andfetus [27,28]. These risks are discussed separately, as are monitoring of metabolic parameters in pregnantpatients taking second-generation antipsychotics and the efficacy, dose, reproductive safety, pharmacology,and side effects of fluoxetine and olanzapine. (See Bipolar disorder in women: Preconception and prenatalmaintenance pharmacotherapy , section on 'Metabolic complications' and Bipolar disorder in adults:Teratogenic and postnatal risks of pharmacotherapy  and Selective serotonin reuptake inhibitors:Pharmacology, administration, and side effects  and Second-generation antipsychotic medications:Pharmacology, administration, and comparative side effects  and Bipolar disorder in adults:Pharmacotherapy for acute depression .)Specific medication interactions that can occur may be determined using the drug interactions tool (Lexi-Interact Online) included in UpToDate. This tool can be accessed from the online search page or through theindividual drug information topics in the section on Drug Interactions.●Lamotrigine  plus lithium – For pregnant patients with bipolar major depression who do not respond to or toleratefluoxetine plusolanzapine, we suggest lamotrigine plus lithium [11]. Fluoxetine plus olanzapine are usually tapered and discontinued concurrently over a period of one week, and subsequently lamotrigine andlithium are started and titrated up. Fluoxetine is generally tapered by the same amount for each dosedecrease, as is olanzapine. As an example, fluoxetine 40 mg per day is decreased by 10 mg per day everytwo days, and olanzapine 15 mg per day is decreased by 5 mg per day every three days. Although lithium is generally regarded as teratogenic due to increased risks of cardiac defects (eg, Ebstein’sanomaly) [29-31], many authorities consider the absolute risk small [1,4,18,33,34]. The reproductive safety profile of lamotrigine is generally regraded as favorable [4,17,18], based primarily upon studies of patientswith epilepsy. (See Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy , sectionon 'Lithium' and Risks associated with epilepsy and pregnancy , section on 'Lamotrigine'.) The dose schedule, side effects (table 4 andtable 5) (including life-threatening skin rash), and pharmacology of lamotrigine are discussed separately; as are the use of lithium during pregnancy,dose, use of serumconcentrations to establish the proper dose, side effects, and pharmacology of lithium. (See Bipolar disorder in adults: Maintenance treatment , section on 'Lamotrigine' and Pharmacology of antiepileptic drugs , sectionon 'Lamotrigine' and Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy ,section on 'Refractory patients' and Bipolar disorder in adults and lithium: Pharmacology, administration, andside effects .)Specific medication interactions that can occur may be determined using the drug interactions tool (Lexi-Interact Online) included in UpToDate. This tool can be accessed from the online search page or through theindividual drug information topics in the section on Drug Interactions.● Electroconvulsive therapy (ECT)  – For refractory pregnant patients with bipolar major depression thatdoes not respond to sequential trials of lamotrigine,quetiapine,fluoxetine plusolanzapine, and lamotrigine pluslithium, we suggest electroconvulsive therapy (ECT). Lamotrigine and lithium are tapered anddiscontinued over a period of one to two weeks prior to starting ECT. Lamotrigine isgenerally tapered by thesame amount for each dose decrease, as is lithium. As an example, lamotrigine 200 mgper day is decreasedby 50 mg per day every three to four days, and lithium 1200 mg per day is tapered by300 mg per day everythree to four days.Reviews have found that ECT is efficacious and safe for patients with bipolar major depression who are not● Bipolar disorder in pregnant women: Treatment of major depressionhttp://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women...3 de 1402/12/2013 04:41  ADJUNCTIVE TREATMENTPsychotherapy  — For pregnant patients with bipolar major depression who are treated with pharmacotherapy,we suggest adjunctive psychotherapy based upon randomized trials in nonpregnant patients [2,6,43]. As anexample, a one-year randomized trial compared intensive psychotherapy plus pharmacotherapy with brief psychoeducation plus pharmacotherapy in 293 nonpregnant patients with bipolar major depression [44]. Intensivepsychotherapy consisted of family therapy, cognitive-behavioral therapy, or interpersonal and social rhythmtherapy, with up to 30 sessions (50 minutes each) administered over nine months; brief psychoeducation includedthree 50-minute sessions instructing patients about the clinical features and treatment of bipolar disorder. Recoveryoccurred in more patients who received adjunctive intensive psychotherapy compared with brief psychoeducation(64 versus 52 percent), and outcome did not differ significantly among the three intensive therapies. Usingpsychotherapy is also supported by randomized trials in pregnant patients with unipolar major depression [45], andis consistent with treatment guidelines [26]. Omega-3 fatty acids  — For pregnant patients with bipolar major depression, dietary supplementation withomega-3 fatty acids (eg, eicosapentaenoic acid 1 to 2 grams per day) as adjunctive treatment is reasonable,based upon limited evidence in meta-analyses of randomized trials (which excluded pregnant patients) [46,47] andthe apparent lack of serious side effects. In addition, prenatal intake of omega-3 fatty acid supplements may havemodest beneficial effects on fetal neurodevelopment, and do not have known harmful effects. The efficacy of omega-3 fatty acids and the risks and benefits during pregnancy are discussed separately. (See Bipolar disorder in adults: Pharmacotherapy for acute depression  and Risks and benefits of fish consumption and fish oilsupplements during pregnancy .) RESIDUAL INSOMNIA  — Bipolar major depression in pregnant patients often includes insomnia, which may persistdespite resolution of the depressive syndrome. For patients with residual insomnia, we suggest behavioral therapy,including education about sleep hygiene (table 6) and stimulus control (table 7). Patients unresponsive to behavior  therapy typically receive additional treatment with low dosedoxepin. Treatment of insomnia is discussedseparately. (See Treatment of insomnia .) INFORMATION FOR PATIENTS  — UpToDate offers two types of patient education materials, “The Basics” and“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 gradereading level, and they answer the four or five key questions a patient might have about a given condition. Thesearticles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyondthe Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are writtenat the 10 to 12 grade reading level and are best for patients who want in-depth information and arecomfortablewith some medical jargon.Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail thesetopics to your patients. (You can also locate patient education articles on a variety of subjects by searching on“patient info” and the keyword(s) of interest.)These educational materials can be used as part of psychoeducational psychotherapy. (See Bipolar disorder inadults: Maintenance treatment , section on 'Psychoeducation'.)pregnant [35,36], as well as patients who are pregnant [37,38]; ECT is thus recommended by several practice guidelines [7,39-42]. The efficacy, adverse maternal and fetal effects, and reproductive safety of ECT are discussed separately, as is the technique for performing ECT during pregnancy. (See Bipolar disorder in postpartum women: Treatment , section on 'Electroconvulsive therapy (ECT)' and Bipolar disorder in pregnant women: Treatment of mania and hypomania , section on 'Electroconvulsive therapy' and Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy , section on'Electroconvulsive therapy' and Technique for performing electroconvulsive therapy (ECT) in adults , sectionon 'Pregnancy'.) thththth Basics topics (See Patient information: Bipolar disorder (The Basics)  and Patient information: Reducing the costs of medicines (The Basics) .)●Beyond the Basics topics (See Patient information: Bipolar disorder (manic depression) (Beyond theBasics)  and Patient information: Reducing the costs of medicines (Beyond the Basics) .) ● Bipolar disorder in pregnant women: Treatment of major depressionhttp://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women...4 de 1402/12/2013 04:41
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks