MOOD-STABILIZING AGENTS

Four mood stabilizers in common use: lithium, valproic acid, carbamazepine/oxcarbazepine, and lamotrigine (Table 200-4). Lithium is the gold standard and the best studied, and along with carbamazepine and valproic acid, is used for treatment of acute manic episodes; 1–2 weeks to reach full effect. As prophylaxis, the mood stabilizers reduce frequency and severity of both manic and depressed episodes in cyclical mood disorders. In refractory bipolar disorder, combinations of mood stabilizers may be beneficial.
TABLE 200-4: Clinical Pharmacology of Mood Stabilizers
AGENT AND DOSINGSIDE EFFECTS AND OTHER EFFECTS
LithiumCommon Side Effects
Starting dose: 300 mg bid or tid
Therapeutic blood level: 0.8–1.2 meq/L
Nausea/anorexia/diarrhea, fine tremor, thirst, polyuria, fatigue, weight gain, acne, folliculitis, neutrophilia, hypothyroidism
Blood level is increased by thiazides, tetracyclines, and NSAIDs
Blood level is decreased by bronchodilators, verapamil, and carbonic anhydrase inhibitors
Rare side effects: Neurotoxicity, renal toxicity, hypercalcemia, ECG changes
Valproic AcidCommon Side Effects
Starting dose: 250 mg tid
Therapeutic blood level: 50–125 µg/mL
Nausea/anorexia, weight gain, sedation, tremor, rash, alopecia
Inhibits hepatic metabolism of other medications
Rare side effects: Pancreatitis, hepatotoxicity, Stevens-Johnson syndrome
Carbamazepine/OxcarbazepineCommon Side Effects
Starting dose: 200 mg bid for carbamazepine, 150 mg bid for oxcarbazepine
Therapeutic blood level: 4–12 µg/mL for carbamazepine
Nausea/anorexia, sedation, rash, dizziness/ataxia
Carbamazepine, but not oxcarbazepine, induces hepatic metabolism of other medications
Rare side effects: Hyponatremia, agranulocytosis, Stevens-Johnson syndrome
LamotrigineCommon Side Effects
Starting dose: 25 mg/d
Rash, dizziness, headache, tremor, sedation, nausea
Rare side effect: Stevens-Johnson syndrome
Abbreviations: ECG, electrocardiogram; NSAIDs, nonsteroidal anti-inflammatory drugs.

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