18. Consensus Guidelines: Initial Treatment Regimen Bipolar I Add BZD to either agent MS alone MS + AP AP alone Mania with psychosis Combination of two MS Add a BZD to either agent AP alone MS + AP MS alone Mania with history of rapid cycling Add BZD to either agent AP alone Combination of two MS MS + AP MS alone Dysphoric mania or true mixed mania AP alone MS alone MS + AP Add a BZD to other agents Euphoric mania Alternate Strategies Preferred Initial Strategies Clinical Presentation
19. Consensus Guidelines: Inadequate Response to Initial Treatment Add different MS Replace the MS with different MS Replace the current AAP with a different AAP MS + AAP Switch to a MS Add a MS Monotherapy With an AAP Add an AAP Add a different MS Monotherapy With a MS Alternate Strategies Preferred Strategies Initial Treatment
20. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 0.8-1.2 mEq/L 300-900 mg Level of 1.2 mEq/l Lithium EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
21. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 125 microgra/ml 250-500 HS for 2 days Oral load 30 mg/kg/d DVP EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
22. TREATMENT OF MANIA Lithium and Anticonvulsant _ 125 microgra/ml 750 mg/day Oral load 30 mg/kg/d DVP ER EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
23. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 125 microgra/ml 250-500 HS for 2 days Oral load 30 mg/kg/d DVP EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
24. TREATMENT OF MANIA Lithium and Anticonvulsant + 1600 mg/day 200 mg HS, BID or TID 800-1000mg CBZ EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
25. TREATMENT OF MANIA Lithium and Anticonvulsant + 1600 mg/day 400 mg/day 800-1000mg CBZ ER EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE
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27. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING 30 mg 5-15 m/day 15-30 mg Aripriprazole Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
28. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING + 30 mg 12.5-25 mg BID 100-900 QD or BID Cloz Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
29. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING ++ 40 mg 5-10 mg HS; also 40 mg dis 15-30 mg QD or BID OLZ Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
30. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 800 mg 25-200 mg HS 400-800 mg QD or BID Queti Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
31. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 6 mg 1-6 mg Ris Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
32. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 160 mg 20-40 mg BID 40-160 mg QD or BID Zip Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute
33. Tolerability of Bipolar agents Other than antipsychotics = ++ 0 + + Lamotrigene ++ +++ 0 +++ + Cabamazepin ++ + 0 ++ ++ Divaloprex +++ ++ 0 +++ ++ Lithium GI Derm EPS CNS Weight gain Drugs
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44. GUIDELINES FOR TREATMENT OF BIPOLAR DISORDER Utilize life charting Monitor patient and recognize that the course may change over time Educate patient and significant others Restore psychosocial functioning
45. GUIDELINES FOR TREATMENT OF BIPOLAR DISORDER Explore aggressive treatment strategies (eg loading strategies, ER formulations ) Individual treatment Treat entire illness, not just episode Accurate diagnosis-remission and ultimate recovery