This journal club will compare the following two recent guidelines for the management of bipolar depression:
Hello friends welcome to psychiatry education for ins journal club number five i am dr. harvinder singh so without wasting any time let’s discuss what topic are we going to discuss today so the topic is very interesting one i will be comparing these two guidelines for published for bipolar depression so the first guideline is can mit and is b d guideline published
In 2018 i will be comparing this with most recent guidelines or i should say update published by harvard south shore program so before i go into that very briefly about these two articles they both were published and bipolar disorders journal so the first is our canadian network for mood and anxiety treatments we call this can mit and international society for
Bipolar disorders is b d they actually published these guidelines for bipolar disorder together very highly recommended article i will place these links below if you’re interested in reading more details about them and then i will be comparing them with our most recent update published by the psychopharmacology algorithm project at b harvard south to your program
And this update was only on bipolar depression recently to make it more easy and simple i will try my best not to go into details of that otherwise this journal club will become more than one hour long i will be very quick very brief about just a brief overview of the medication recommendation so i will be using this format here on the left side i will name the
Recommendation by can met and is b d and on the right side it’s harvard south shore program recommendation and i will be comparing first line then second line then third line recommendation and in the end we’ll see what medications are not recommended by both of these guidelines so starting with the first line treatment before i go into first line treatment there
Was an interesting thing i noticed with canned meat and is bd so they recommend that medication on top should be used first followed by medications below that which harvard south shore program i believe was not mentioning that so which medication is recommended on top among first-line treatment so according to can mid and is bd guideline they recommend could type
In on top with level of evidence one followed by using leer acid on as a augmentation agent not alone butler acid own as an argumentation agent with lithium or depakote and then we go to lithium very important medication although not fda approved for bipolar depression but here it’s in first-line treatment then we have lamotrigine followed by a lower acid on so
Again i will repeat the acid on augmentation is on top your acid down alone as below and then in the end lamotrigine as an adjunct like an augmentation agent here adjunct treatment so i will not go into those level of evidence treatment here so this is the first-line recommendation by can mate and is vd and they recommend that first-line treatment option should
Be tried for adequate doses and duration before considering second line option i will not go into details of that but very briefly they recommend lithium level to be at least point eight or more to have good response and also for maintenance treatment quetiapine was close to 300 milligram per day dosing lamotrigine i believe was also close to 200 milligram per
Day dosing so this was first line treatment per can man and is beating for the second line treatment same thing top-down approach they recommend first in second line was mono therapy with the dial pro x which is the depakote although evidence is not that strong but this was second line treatment here and then they also recommend in second line adjunctive use of
Antidepressant here not alone obviously which we will talk it’s the adjunctive use of antidepressant treatment either ssri or bupropion would let him or depakote or any other atypical antipsychotic this was second line and then they also mentioned ect here and mostly we know is it is very good for treatment-resistant patient or in patients you need very rapid
Treatment you see t’s second line here and then kerosene is second line here per can mate and is vd and then we have the combination of olanzapine and fluoxetine we know that olanzapine and fluoxetine is fda-approved so very briefly you can see that there are many medication in both first line and second line which are every fda approved and many of them are not
Fda approved but very interesting and very useful table that we should know when choosing and discussing medications with our patient this was first in second line how about third line recommendation per can meet and is bd so they say you know obviously patient who have not responded or failed first and second line then you should go to third line in third line
Let’s discuss mono therapy first and then we will discuss the adjunctive treatment recommendation here the interesting thing is in mono therapy the carbamazepine was there and olanzapine alone was here we’ll talk about why this is interesting in few minutes in adjunctive treatment they recommend airy papers all alone and then as pina loan these were the two
Antipsychotics and then we have modafinil armodafinil and then pramipexole and then we have iii weak sorry levothyroxine iv ketamine rtms an interesting thing is adjunctive s nri or mao is were also here and then we have sleep deprivation plus light therapy very interesting one good data for this one not a lot but good data and then omega-3 fatty acid so this
Was a very brief overview of third-line recommendation per can maiden is beauty guidelines and then last is the not recommended treatment here so first thing is definitely antidepressant mono therapy is a big no although there is some new data coming in but this is a big know as a mono therapy if you ever use antidepressant should be after a person is on a
Very stable those of mood stabilizers i’m not going to discuss that here the other medication not recommended was re pepra zorb alone ziprasidone alone lamotrigine plus folic acid and adjunctive use of meifa preston so be mindful that when we looked at third line treatment right arif appraisal was used as an adjunct but arup appraisal alone have no africa scene
Bipolar depression i do see some time these this medication prescribed for bipolar depression but no data out there to support that now let’s go back to where we started so level so we talked about can met and is beauty guidelines now i’m going to compare this with the harvard south shore recommendation or update for bipolar depression the interesting thing is
Harvard south shore recommend it’s very similar medication but they don’t recommend priority of one medication another they recommend keeping things in mind like if patient have history of mania or hypomania before for maintenance treatment you should keep all those things in mind before choosing one medication over another so first-line treatment according to
Them is quetiapine very same can rip regime now this is a different difference from the can meet and is bida guidelines you see carrie prejean was second line there well we are i think we all know the reason for that carrie prejean was initially fda approved i think in 2015 for mania with or without mix feature but just recently in june of 2019 carrie present
Got fda approval for bipolar depression so can mit and i a speedy guidelines are little older there i was assuming that this change will happen carry pros in will move up and we saw that change in the harbor south shore update so carrie prejean is level first line now latia ms still first line lamotrigine is still first line laura sedona still first line so the
Difference is curry prisoners up now in first line because this is also fda approved medication now how about second line treatment what’s different here well we see divalproex depe corp still there among antidepressant though this was interesting when you look at the tables in the harvard south shore update they say tribe appropriate definitely as an adjunct not
Alone but the pro pian is first and then ssri so that’s one difference here compared to can mit and nothing else is there in the second line so far so this is the difference and i just marked that for olanzapine and fluoxetine we’ll talk about that in a few minutes olanzapine plus fluoxetine is no longer even in the second line we’ll talk about that very soon
Now this was a difference in first line and second line treatment how about the third line let’s discuss that so airy pip rizzo was used here as at third line then clozapine and then here in addition to modafinil and armodafinil they also recommend stimulants well please note these are all adjunct treatment sorry i forgot to mention that these are all adjunct
Treatment not alone arab appraisal some studies on clozapine for cross between the interesting thing is it was all um what do you call no control studies were there this was based on open label reports stimulants and then amongst timberlands there is some data for methylphenidate and i think list death less dex and feta mean i can never say it had in a nice way
And then modafinil are modafinil interesting thing is on these studies they do improve you know depression but i believe that was more due to improvement in energy symptoms and there was no manic switch i always worry about manic switch with these dopamine agonist medication so moving on pramipexole is still here as a third line levothyroxine is still here t3
As third line are tms is here sleep deprivation plus light therapies here and omega-3 fatty acid so basic difference you see in third line is clozapine was mentioned here in harvard south shore update stimulants were mentioned here carbamazepine was not mentioned here not even olanzapine so these things are very important not even a centipede i should say yeah
So these were the main difference in third line so where did these medications oh let’s find out in our last section which is not recommended treatment here so the first thing that was not recommended was combination of olanzapine and fluoxetine now this was interesting i had reviewed this article because this they mentioned you know despite olanzapine plus
Fluoxetine carrying fda approval the risk is very high because of the metabolic effect that olanzapine contributes for the long term risk in terms of morbidity and mortality so they would mention if somebody was on this consider tapering that medication so this was one important lesson from this update to avoid this combination unless obviously if somebody is
Stable on that that’s another story but the risk is high based on that even re-pipe result was not recommended just like the old updates but there were other anti-psychotic like the proceed own and olanzapine alone same thinking that olanzapine even one dose of olanzapine can increase that side effect profile drastically the metabolic derangement can be very
High so olanzapine is one medication they were not supportive of and then other medication which are not recommended by harvard south shore update is carbamazepine and oxcarbazepine you might remember that carbamazepine was a third line pork and mit and is very guidelines here it’s not recommended because the data is not strong or not there for both of these
Medication it’s not sufficient to support the efficacy in bipolar depression so the main difference that we saw so far is combination of all ann’s opinion fluoxetine is here and the olanzapine part and carbamazepine and oxcarbazepine are not indicated i will place the link below if you are interested in reviewing these slides i will put them on our website psychiatry
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Get all that so again friend thank you i’m dr. harvin they’re saying thanks for listening very briefly before i end if you have not subscribed to our course physician guide for clinical psychiatry course please do that and i’m very excited actually very soon i’m about to announce very big news for our website so stay tuned hopefully next week or so you will find
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Transcribed from video
Journal Club #5: Comparing Bipolar Depression Guidelines (CANMAT & ISBD 2018 vs HSS 2019) By Psychiatry Education Forum
