File size: 15,879 Bytes
3530638 |
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 |
#### Table 12. Hierarchical rankings of first and second‐line treatments recommended for management of acute mania ##### First-line treatments: Monotherapies ###### Lithium ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 1 evidence. Prevention of mania during maintenance: level 1 evidence. Prevention of depression during maintenance: level 1 evidence. Acute depression: level 2 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Quetiapine ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 1 evidence. Prevention of mania during maintenance: level 1 evidence. Prevention of depression during maintenance: level 1 evidence. Acute depression: level 1 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Divalproex ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 1 evidence. Prevention of mania during maintenance: level 3 evidence. Prevention of depression during maintenance: level 2 evidence. Acute depression: level 2 evidence. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection. Maintenance phase tolerability concerns: minor impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Asenapine ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: level 2 evidence. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: limited impact on treatment selection. Maintenance phase tolerability concerns: minor impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Aripiprazole ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: no data; although monotherapies are listed above combination therapies in the hierarchy, combination therapies may be indicated as the preferred choice in patients with previous history of partial response to monotherapy and in those with psychotic mania or in situations where rapid response is desirable. Acute depression: level 1 negative evidence. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: limited impact on treatment selection. Maintenance phase tolerability concerns: minor impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Paliperidone(>6mg) ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: no data; although monotherapies are listed above combination therapies in the hierarchy, combination therapies may be indicated as the preferred choice in patients with previous history of partial response to monotherapy and in those with psychotic mania or in situations where rapid response is desirable. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: minor impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Risperidone ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 3 evidence. Prevention of mania during maintenance: level 3 evidence. Prevention of depression during maintenance: no data. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: minor impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Cariprazine ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: no data. Prevention of mania during maintenance: no data. Prevention of depression during maintenance: no data. Acute depression: level 1 evidence. ####### Considerations for treatment selection Acute phase safety concerns: limited impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: limited impact on treatment selection. Maintenance phase tolerability concerns: limited impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ##### First-line treatments: Combination therapies ###### Quetiapine and Lithium/divalproex ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 1 evidence. Prevention of mania during maintenance: level 1 evidence. Prevention of depression during maintenance: level 1 evidence. Acute depression: level 4 evidence; no controlled trials; however, clinical experience suggests that it is a useful strategy. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: significant impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Aripiprazole and Lithium/divalproex ####### Level of evidence by phase of treatment Acute mania: level 2 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: no data; did not separate from placebo in those with index mania; no studies available in index depression. Acute depression: level 4 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Risperidone and Lithium/divalproex ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 4 evidence. Prevention of mania during maintenance: level 4 evidence. Prevention of depression during maintenance: no data. Acute depression: level 4 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: significant impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Asenapine and Lithium/divalproex ####### Level of evidence by phase of treatment Acute mania: level 2 evidence. Prevention of any mood episode during maintenance: level 4 evidence. Prevention of mania during maintenance: level 4 evidence. Prevention of depression during maintenance: no data. Acute depression: level 4 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: minor impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ##### Second-line treatments: Combination therapies ###### Olanzapine ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 1 evidence. Prevention of mania during maintenance: level 1 evidence. Prevention of depression during maintenance: level 1 evidence. Acute depression: level 1 evidence; did not separate from placebo on core symptoms of depression. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: significant impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Carbamazepine ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: level 2 evidence. Acute depression: level 3 evidence. ####### Considerations for treatment selection Acute phase safety concerns: moderate impact on treatment selection. Acute phase tolerability concerns: minor impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Olanzapine and Lithium/divalproex ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 4 evidence. Prevention of mania during maintenance: level 4 evidence. Prevention of depression during maintenance: level 4 evidence. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection; divalproex and carbamazepine should be used with caution in women of childbearing age. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Lithium and divalproex ####### Level of evidence by phase of treatment Acute mania: level 2 evidence. Prevention of any mood episode during maintenance: level 2 evidence. Prevention of mania during maintenance: level 2 evidence. Prevention of depression during maintenance: no data. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Ziprasidone ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: level 3 evidence. Prevention of mania during maintenance: level 3 evidence. Prevention of depression during maintenance: no data. Acute depression: level 1 negative evidence. ####### Considerations for treatment selection Acute phase safety concerns: moderate impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: moderate impact on treatment selection. Maintenance phase tolerability concerns: minor impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. ###### Haloperidol ####### Level of evidence by phase of treatment Acute mania: level 1 evidence. Prevention of any mood episode during maintenance: no data. Prevention of mania during maintenance: level 4 evidence. Prevention of depression during maintenance: level 4 negative evidence. Acute depression: no data. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: significant impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: moderate impact on treatment selection. ###### ECT ####### Level of evidence by phase of treatment Acute mania: level 3 evidence. Prevention of any mood episode during maintenance: level 4 evidence. Prevention of mania during maintenance: level 4 evidence. Prevention of depression during maintenance: level 4 evidence. Acute depression: level 4 evidence. ####### Considerations for treatment selection Acute phase safety concerns: minor impact on treatment selection. Acute phase tolerability concerns: moderate impact on treatment selection. Maintenance phase safety concerns: minor impact on treatment selection. Maintenance phase tolerability concerns: moderate impact on treatment selection. Risk of depressive switch: limited impact on treatment selection. |