The safety and early efficacy of oral-loaded divalproex versus standard-titration divalproex, lithium, olanzapine, and placebo in the treatment of acute mania associated with bipolar disorder

University of Texas Medical Branch at Galveston, Galveston, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.14). 08/2003; 64(7):841-6. DOI: 10.4088/JCP.v64n0717
Source: PubMed

ABSTRACT Previous studies have examined the safety and tolerability of oral-loaded divalproex sodium in the treatment of acute mania, but not the early efficacy of this dosing strategy. The purpose of this study was to evaluate the early efficacy of oral-loaded divalproex.
In this pooled analysis, 348 subjects from 3 randomized, double-blind, parallel-group, active- or placebo-controlled studies were used to compare the efficacy, safety, and tolerability of oral-loaded divalproex with standard-titration divalproex, lithium, olanzapine, or placebo. Subjects were inpatients diagnosed with acute mania associated with bipolar I disorder (DSM-III-R or -IV and SADS-Change Version). Patients were administered oral-loaded divalproex (20 or 30 mg/kg/day on days 1 and 2 followed by 20 mg/kg/day, and increased at physician's discretion), standard-titration divalproex initiated at 250 mg t.i.d. and titrated to 40-150 microg/mL, lithium (300 mg t.i.d. initial dose) titrated to 0.4 to 1.5 mEq/L, olanzapine (10 mg q.d. initial dose) up to 20 mg/day, or placebo.
The results demonstrate an early efficacy advantage for oral-loaded divalproex compared to standard-titration divalproex at days 5, 7/8, and 10. Efficacy was improved over lithium on day 7/8. There were no efficacy differences between divalproex loading and olanzapine. Divalproex loading showed greater efficacy than placebo at all time points. Divalproex loading was as well tolerated or better tolerated than the other active treatments as measured by adverse events and changes in laboratory parameters.
These results suggest the oral loading of divalproex leads to a more rapid antimanic effect when compared with standard-titration divalproex, lithium, or placebo and is better tolerated than olanzapine and as well tolerated as lithium or standard-titration divalproex.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Bipolar disorder is a less common biologic disorder in primary care than are depressive and anxiety disorders, but there is a high risk for poor outcomes for patients. Primary care physicians (PCPs) are assuming increasing responsibility for the care of these patients in today's man-aged care environment, working independently or in collaboration with a psychiatrist. The PCP needs to carefully assess patients presenting with depression, since many are bipolar. The PCP must then skillfully man-age these patients because of the significant morbidity and mortality associated with the disorder. This article outlines a diagnostic approach for patients in primary care practice who present with mood symptoms. The article also presents a management strategy for those who are diagnosed with bipolar disorder, including patients who are considering pregnancy or who are pregnant.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess new treatment options for bipolar disorders. Controlled studies of new treatments for bipolar disorders were identified by computerized searches and reviews of scientific meeting proceedings, and were compiled by drug category. Two main categories of medications, newer anticonvulsants and newer antipsychotics, are yielding emerging new treatment options for bipolar disorders. Newer anticonvulsants have diverse psychotropic profiles, and although not generally effective for acute mania, may have utility for other aspects of bipolar disorders (e.g. lamotrigine for maintenance or acute bipolar depression), or for comorbid conditions (e.g. gabapentin for anxiety or pain, topiramate for obesity, bulimia, alcohol dependence, or migraine, and zonisamide for obesity). In contrast, newer antipsychotics generally appear effective for acute mania, and some may ultimately prove effective in acute depression (e.g. olanzapine combined with fluoxetine, quetiapine) and maintenance (e.g. olanzapine). Emerging research is yielding new treatment options for bipolar disorders and comorbid conditions.
    Acta psychiatrica Scandinavica. Supplementum 02/2004; DOI:10.1111/j.1600-0447.2004.00410.x
  • [Show abstract] [Hide abstract]
    ABSTRACT: Olanzapine (Zyprexa, Eli Lilly & Co.) is an atypical antipsychotic medication with once-daily dosing that was originally developed for the treatment of schizophrenia. It has shown broad efficacy in the treatment of bipolar mixed and manic episodes, but is less effective in the treatment of bipolar depression. Double-blind studies have demonstrated a rapid onset of action in acute bipolar mania, significantly greater rates of response compared with placebo, and a remission rate of 88.3% in a 49-week open-label study. Diverse presentations of the illness responded well to olanzapine including patients with rapid-cycling bipolar disorder, mixed episodes, as well as psychotic and nonpsychotic manias. Olanzapine monotherapy improved symptoms of depression related to its sedating and appetite-enhancing profile, but core symptoms such as depressed mood did not improve significantly. However, in combination with fluoxetine, bipolar depressed patients responded without an increased risk of mania. Weight gain and sedation are prominent adverse effects, and it has been associated with atherogenic dyslipidemia and glucose intolerance.
    Expert Review of Neurotherapeutics 10/2004; 4(5):759-67. DOI:10.1586/14737175.4.5.759 · 2.83 Impact Factor
Show more