Pharmacological Treatment Considerations for Bipolar Disorder


A psychiatric mental health nurse practitioner shares her approach to treating bipolar 1 disorder and considers the role of comorbidities in shaping treatment selection for patients.

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC:Atypical antipsychotics for patients with bipolar disorder are generally indicated, especially those that are FDA [Food and Drug Administration] indicated for treating bipolar mania, depression, or mixed features. When we're talking about someone who is over the age of 65, we know that atypical antipsychotics have a significant amount of black box warnings that can contribute to more cardiovascular issues and falls for this particular population. However, in this particular patient's case, she was effectively maintained on lithium for quite a long time. Right now, we're not so worried about her manic or hypomanic episodes. We're more focused on her depressive episodes. The potential to add on an atypical antipsychotic could be very effective and potentially replace the lithium especially if we use a more advanced medication–a newer medication to treat those particular symptoms so basically that we would be able to replace lithium with an atypical antipsychotic that's able to manage both the mania–hypomania features as well as the depressive features and have less potential for interaction among the medication she's already taking.

At this point in time, there are only 3 or 4 medications on the market that are specifically indicated for bipolar 1 depression. Of those, they are atypical antipsychotics and they also carry that black box warning, especially for those over the age of 65. For this particular patient, in this case, you would want to make sure to choose a medication that will play nicely in the sandbox, so to speak, with the other medications that she has onboard and not potentially increase her risk of adverse drug reactions such as falls or increased UTIs [urinary tract infections] or confusion. When we're talking about medications in that aspect, we also want to think about the symptoms and how they present for this patient. With a history of mania or hypomania or thinking of things when we're talking about neurotransmitters like dopamine receptor D2 and D3 and then serotonin 5-HT2A and 1A and 2C, when we're thinking about those particular neurotransmitters, we want to make sure that we select a medication that is going to work at the root of the patient's presentation. For someone who's presenting with more depressed features, we want to consider a medication that's going to work both on serotonin as well as dopamine so newer medications as Dr. Stephen Stahl, MD, PhD, refers to as “Two Pips and a Rip”. We're talking about aripiprazole, brexpiprazole, and cariprazine. Those medications have less interactive medication profiles where they don't necessarily interact with other meds the patient may be taking. Those might be a better option for this particular patient, considering the metformin, Invokana [canagliflozin], olmesartan, the rosuvastatin and the PRN nitrofurantoin that she's taking.

For patients with bipolar disorder whether it's bipolar 1, 2, or any of the myriad of presentations, we really do have to consider the potential for adverse drug reactions from the medications that we prescribe. Traditional atypical antipsychotics, particularly second-generation, do have a high risk of metabolic side effect. Many of these medications increase insulin resistance, cause increased appetite, which results in weight gain. It can have the potential to affect their circulatory system and their blood pressure and things like that. When you're looking at a patient like this one in the example that already has an established history of diabetes, hypertension, and high cholesterol, you're already kind of pushing out many of the atypical antipsychotics that could potentially be effective for this patient simply because they have the risk to increase these particular issues for this patient. This patient has been well maintained for her diabetes, her hypertension, and her cholesterol issues with the medications that she's been taking for well over 10 years in most cases. You want to make sure that you're selecting a medication that is not going to exacerbate those particular symptoms and make them worse. Again, when you're looking at atypical antipsychotics, especially considering monotherapy, you're going to choose something that has a much cleaner metabolic profile so that you're not potentially causing more complications for the patient.

Transcript Edited for Clarity

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