Antipsychotic Medication For Bipolar Depression
Antipsychotics were initially developed to handle the psychotic symptoms that accompany schizophrenia, but now have been found to work for a number of conditions. Taking an antipsychotic does not indicate the person is suffering from psychosis, but antipsychotic medications can be used to manage the psychosis that can come with depression, mania and mixed episodes.
Older generation antipsychotics like chlorpromazine and haloperidol have fallen out of use in favor of the newer atypical antipsychotics. Atypical antipsychotics are thought to have fewer movement disorder side effects but may have additional risks in other areas. Atypical antipsychotics used in treatment include:
Learn more about Antipsychotic Medications for Bipolar Disorder.
Caplyta Gained Indications As Monotherapy And Adjunctive Treatment
byKristen Monaco, Staff Writer, MedPage Today December 20, 2021
The FDA approved lumateperone for bipolar-related depressive episodes, Intra-Cellular Therapies announced Monday.
The atypical antipsychotic gained an indication for the treatment of depressive episodes associated with bipolar I or II disorder in adults, as monotherapy and as adjunctive therapy with lithium or valproate. It was first approved for adults with schizophrenia in December 2019.
Although the novel drug’s the mechanism of action is “unknown,” the treatment’s effect may be mediated through a combination of antagonist activity at central serotonin 5-HT2A receptors and postsynaptic antagonist activity at central dopamine D2 receptors, according to drug developer Intra-Cellular Therapies.
The once-daily oral treatment can be taken with or without food. The label states that the recommended 42-mg dose does not require titration.
Lumateperone does carry a boxed warning label regarding increased mortality in elderly patients with dementia-related psychosis, as well as a possible increased risk for suicidal thoughts and behaviors in pediatric and young adult patients.
Of note, lumateperone did not cause weight gain, a side effect common with antipsychotics. In fact, the weren’t any significant changes from baseline in regards to key metabolic markers — weight, fasting glucose, total cholesterol, triglycerides, or LDL cholesterol — compared with placebo.
Depression In Bipolar Disorder
Treating bipolar depression is controversial and challenging. Studies have shown that antidepressants may be less effective in treating bipolar depression than they are in treating unipolar depression . Also using antidepressants alone may trigger a manic or hypomanic episode in some people with bipolar disorder.
Antidepressants alone also may lead to or prolong rapid cycling. In rapid cycling, a person may recover more quickly from depression but then experience mania followed by another episode of depression. And antidepressants can increase the risk of suicidal thoughts and attempts in children and adolescents with any form of depression.
Three drugs are FDA-approved for the treatment of bipolar depression: quetiapine by itself, olanzapine when used with fluoxetine , and lurasidone used alone or with lithium or valproate . The atypical antipsychotic drug cariprazine has also shown promise in initial studies to treat bipolar depression.
There are also a number of treatments that have begun to show promise in research studies for treating bipolar depression, including the Parkinson’s disease drug pramipexole dihydrochloride , the wakefulness drugs modafinil and armodafinil , the nutritional supplement n-acetylcysteine, and the intravenous anesthetic drug ketamine.
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Fda Approves Caplyta For Depressive Episodes In Bipolar I Ii Disorders
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The FDA has approved Caplyta for treating adults with depressive episodes linked to bipolar I or II disorder, according to a company press release.
The approval covers Caplyta as monotherapy and as adjunctive therapy with lithium or valproate.
Caplyta has shown a consistent favorable profile on weight, cardiometabolic parameters and extrapyramidal symptoms ,Sharon Mates, PhD, chairman and CEO of Intra-Cellular Therapies, said in the release. We are positioned to launch immediately and are excited to offer Caplyta to the millions of patients living with bipolar depression.
The FDA based its approval on two positive phase 3 placebo-controlled studies of bipolar depression that examined the effects of lumateperone among adults with bipolar I or bipolar II disorder as monotherapy and as adjunctive therapy with lithium or valproate.
Lumateperone 42 mg correlated with statistically significant improvements vs. placebo in change from baseline on the Montgomery-Asberg Depression Rating scale total score at 6 weeks. It also demonstrated statistically significant improvement on the key secondary endpoint of clinical global impression of bipolar disorder in each study, as well as a favorable tolerability and safety profile consistent with results of prior clinical studies in schizophrenia.
Fda Approves Ind Application For Cbd
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The FDA has granted investigational drug designation to Ananda Scientific Inc. for Nantheia ATL5, a liquid augmentative cannabidiol-based treatment for opioid use disorder, according to a company press release.
This is the fourth IND approval for our investigational drug Nantheia product line, and it further reinforces our vision of developing CBD as a therapeutic for a number of key indications, said Ananda CEO Sohail R. Zaidi.
An upcoming clinical trial for Nantheia ATL5 will take place at the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA.
This clinical study at UCLA is an important component of our clinical development efforts focused on opioid addiction, where a non-addictive therapy is a significant unmet need, Zaidi said.
The trial will be funded by the National Institute on Drug Abuse.
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Mania In Bipolar Disorder
If you are suffering from bipolar mania, your doctor at first may treat you with an anti-manic mood stabilizer and sometimes also an antipsychotic drug and/or a benzodiazepine to quickly control hyperactivity, sleeplessness, hostility, and irritability.
Mood stabilizers treat manias or depressions without causing symptoms to swing the other way. Some also may help to reduce the risk of suicide. They are usually taken for a long time, commonly for many years. Examples include lithium and certain anticonvulsant drugs such as carbamazepine , lamotrigine or valproate . Atypical antipsychotics used to treat mania include aripiprazole , asenapine , cariprazine , olanzapine ,quetiapine , risperidone, and ziprasidone .
Treating bipolar mania often requires hospitalization because there is high risk for unpredictable, reckless behavior and noncompliance with treatment. For people with extreme mania, pregnant women with mania, or those people whose mania can’t be controlled with mood stabilizers, doctors sometimes also recommend electroconvulsive therapy .
If mania occurs while you are on maintenance therapy, your doctor may simply change your medication dose. Or you may start taking an antipsychotic drug or a second mood stabilizer to lessen symptoms. Also, antidepressants should usually be discontinued while someone is manic, because they can worsen the symptoms of mania.
Fda Approves Caplyta For Bipolar Depression In Adults
US biotech Intra-Cellular Therapies saw its shares gain 6.3% to $48.20, after it revealed that the US
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Bipolar Depression Medication Cocktails
Most people with bipolar depression who are successfully treated, often take several drugs simultaneously, sometimes called a medication cocktail. Results from a recent research project called the STEP-BD Project found 89% of those successfully treated for bipolar disorder required, on average, three medications from the above categories.
Mood Stabilizers Like Lithium For Bipolar Depression
There are many mood stabilizers used in the treatment of bipolar depression. Some of the common mood stabilizers include:
In reality, only Lithium is a true mood stabilizer. The other medications are anticonvulsants that were created for epilepsy and were found to work on mood disorders. Valproate , carbamazepine , and oxcarbazepine work for mania, but only lamotrigine and lithium has been shown to manage depression.1
Learn more about Mood Stabilizers for Bipolar Disorder.
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Prescribing For Bipolar Disorder
Discrepancies remain with recommendations made by the PAPHSS and other guidelines for bipolar depression. The differences are largely due to the PAPHSS emphasis on long-term adverse effects associated with potential treatments. When providing recommendations, other guidelines do not weigh adverse effects heavily in making their recommendations.
For example, here is a brief look at other clinical practice guidelines for treating bipolar disorder:
- The Canadian Network of Mood and Anxiety Treatments and International Society for Bipolar Disorders 2018 guideline update recommends quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine as first-line therapies for bipolar I.21
- The International College of Neuro-Psychopharmacology 2016 treatment Guidelines for Bipolar Disorder in Adults recommends lurasidone and quetiapine as first-line options. They note fluoxetine, escitalopram, olanzapine, and OFC as second-line recommendations with lithium recommended only after other options have failed.22
Fda Approves New Treatment For Bipolar Depression
Caplyta is the only drug FDA-approved for depressive episodes from bipolar I and II. The US Food and Drug Administration has approved Caplyta for the treatment of bipolar depression in adults. Caplyta, an atypical antipsychotic from biopharmaceutical company Intra-Cellular Therapies, is the only drug approved by the…
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Olanzapine And Fluoxetine Combination
As an alternative treatment, the use of olanzapine and fluoxetine combination is also approved for acute bipolar depression. However, due to significant metabolic effects resulting in long-term risk for morbidity and mortality, OFC is not recommended early on in treatment. The use of OFC should be reserved until after all the aforementioned first-line medications and valproate have been trialed .
In studies comparing OFC to lamotrigine, similar remission rates were found in both arms however, lamotrigine was better tolerated.16 Recent meta-analysis show combinations of second-generation antipsychotics and antidepressants do not provide the same effectiveness as OFC.2
Fda Releases Guidelines For Bipolar Disorder And Depression
Patients with bipolar disorder may experience a whirlwind of emotions, constantly shifting, dipping or erupting without notice. Though bipolar disorder cannot be cured, there are a number of existing drugs used for bipolar treatment.
The Food and Drug Administration has approved a number of medications and treatment options for individuals struggling to manage bipolar disorder. On Dec. 1, the organization issued a set of FDA guidelines to help patients better understand the condition, in addition to a set of guidelines for identifying and treating depression.
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Fda Approves Lumateperone For Bipolar Depression
The treatment is approved as either a monotherapy or an adjunctive therapy with either lithium or valproate.
The US Food and Drug Administration has approved lumateperone for adults with bipolar depression.
The treatment, developed by Intra-Cellular Therapies, represents the only FDA-approved therapy for depressive episodes associated with bipolar depression, both as a monotherapy and an adjunctive therapy with either lithium or valproate.
The approval is based on favorable safety, tolerability, and efficacy from a pair of positive phase 3 placebo-controlled bipolar depression studies.
The investigators found lumateperone 42 mg resulted in a statistically significant improvement over placebo in the change from baseline in the Montgomery-Asberg Depression Ratings scale total score at week 6, as well as a statistically significant improvement in key secondary endpoints relating to the clinical global impression of bipolar disorder in each study.
The treatment was also deemed safe and tolerable, with a safety profile consistent with previous findings for the treatment of schizophrenia. The most common adverse reactions included somnolence/sedation, dizziness, nausea, and dry mouth. The mean changes from baseline in weight, fasting glucose, total cholesterol, triglycerides, and LDL cholesterol were also similar between lumateperone and placebo.
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When To Avoid Lumateperone
- Hepatic impairment: moderate or severe
- Moderate CYP3A4 Inhibitors: Amprenavir, ciprofloxacin, cyclosporine, diltiazem, erythromycin, fluconazole, fluvoxamine, verapamil.
- Strong CYP3A4 Inhibitors: Clarithromycin, grapefruit juice, itraconazole, voriconazole, nefazodone, ritonavir, nelfinavir.
- Breastfeeding: recommended to avoid breastfeeding with Lumateperone.
What Is Bipolar Disorder
Bipolar disorder is a brain condition characterized by shifts in chemicals, which cause changes in mood and behavior. There are two types of bipolar disorder: type I and type II. The FDA asserts the importance of diagnosis for proper treatment.
Bipolar I, also referred to as manic depression, involves deep states of depression followed by manic energy. Bipolar I is characterized by unusual shifts in mood, energy, activity levels, and the lack of ability to do everyday tasks.
People with bipolar II experience a less intense form of hypomania, known as a manic episode. During the hypomania stage, individuals can be extremely productive and exhibit no symptoms of depression. However, bipolar II patients may rapidly drop into a depressive state.
Symptoms of depression include:
- Feeling very sad or hopeless
- Lack of energy or motivation
- Feeling like you cant enjoy anything
- Suicidal ideation
- An elevated or irritable mood
- Increased activity and restlessness
- Racing thoughts or talking fast
- A decreased need for sleep
A doctor can complete a medical history, physical exam, and laboratory exam to rule out physical conditions that may cause similar symptoms, according to Mitchell Mathis, M.D., director of the Division of Psychiatry Products at the FDA. If symptoms are not caused by other illnesses, the doctor may then provide a referral to a mental health professional.
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Carbamazepine Oxcarbazepine And Antidepressants
Other agents such as carbamazepine, oxcarbazepine, and antidepressants lack sufficient evidence to treat bipolar depression. The use of antidepressants in bipolar I disorder is widely discouraged. This recommendation follows even when added to a mood stabilizer. This consensus was based on studies showing worse maintenance outcomes when rapid cyclers were given antidepressants.19 On the contrary, the efficacy of antidepressants in bipolar 2 is unclear. More research is required before further recommendations regarding antidepressants in bipolar 2 can be made. Clinicians must properly diagnose individuals according to the DSM-5 criteria before they consider prescribing antidepressants.2
Antidepressants For Bipolar Depression
The most familiar class of depression medications is antidepressants. While antidepressants are sometimes used as medications for bipolar depression, there is always the risk that an antidepressant will trigger mania / hypomania or create rapid cycling between bipolar highs and lows. Some doctors believe antidepressants may worsen long-term outcomes of bipolar disorder as well 2 .
If antidepressants are used to treat bipolar depression, they are combined with the use of a mood stabilizer or atypical antipsychotic medication to prevent the appearance of bipolar mania.
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Bipolar Treatment Depression Medication Risks
Medications used for depression and bipolar treatment come with a number of short and long-term side effects. Two popular treatments, Abilify and Paxil, can cause serious complications in some patients.
Abilify is a second-generation antipsychotic used to treat depression, schizophrenia, autism and bipolar disorder. Abilify has been linked to suicidal thoughts, compulsive behaviors, and problems with impulse control. Some individuals experience a pathological desire to binge eat, gamble, or have sex.
Paxil, a selective serotonin reuptake inhibitor , is approved for depression, though it may be used to treat bipolar disorder. Paxil can cause a number of common side effects, such as nausea, weight gain, diarrhea, and problems with sleep or sex. When used while pregnant, Paxil may cause birth defects. Babies exposed to Paxil in utero also have a higher autism risk.
Its crucial for patients suffering from symptoms related to depression or bipolar disorder to undergo an evaluation, receive a proper diagnosis, and continue to be monitored by a health professional. For individuals who may be in crisis, the FDA urges immediately seek medical attention:
You can call your doctor, go to a hospital emergency room, or even call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK . This line is open 24 hours a day, 7 days a week and all calls are confidential.
Fda Approves Expanded Use Of Vraylar For Bipolar Depression
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The FDA has approved a supplemental New Drug Application, or sNDA, for Vraylar for the expanded use to treat depressive episodes associated with bipolar I disorder in adults, according to a press release.
Vraylar is already approved by the FDA to treat manic or mixed episodes relating to bipolar I disorder in adults. The FDA approval for its expanded indication was based on data from three pivotal trials , according to the press release.
In the trials, cariprazine showed greater improvement on the Montgomery Asberg Depression Rating scale total score from baseline to week 6 compared with placebo. The 1.5-mg dose demonstrated statistical significance over placebo in all trials and the 3-mg dose demonstrated statistical significance over placebo in one of the trials . Common adverse events included nausea, akathisia, restlessness and extrapyramidal symptoms.
Disclosure: Stahl reports consulting for Allergan.
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