Bipolar disorder

Olanzapine has a potential to cause weight gain, prescribers should be aware of this and discuss with patients.

10mg daily adjusted to usual range of 5-20mg daily; doses greater than 10mg daily only after reassessment; maximum 20mg daily.

Usual dose range 2-5mg daily.

If patients have a previous intolerance to antipsychotics, lithium can be used instead. Consider adding lithium if an antipsychotic alone is not sufficiently effective. Lithium carbonate 200mg is equivalent to lithium citrate 509mg.

Dose adjusted according to serum-lithium concentration, doses are initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilised.
Body-weight up to 50kg, initially 200-400mg daily.
Body-weight 50kg and above, initially 0.4-1.2g once daily, alternatively initially 0.4-1.2g daily in 2 divided doses.

Dose adjusted according to serum-lithium concentration, doses are initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilised.
Body-weight up to 50kg, initially 520mg twice daily.
Body-weight 50kg and above, initially 1.04-3.12g daily in 2 divided doses.

Prescribing Notes:

See local protocols for advice on monitoring, side-effects, drug interactions and psychiatric review.
Primary treatment for mania is with an antipsychotic agent. If an antipsychotic is ineffective, consider switching to a trial of a different antipsychotic.
Therapy should be initiated by a specialist and only following medical examination and careful assessment of risk/benefit.
In patients with mania, consider stopping the antidepressant.
Lithium dose is adjusted to achieve a serum lithium concentration within the therapeutic range stated for that individual patient (see Lithium Treatment Plan). If aiming for a different therapeutic range from the normal 0.6-1mmol/L, then this must be clearly communicated to the prescriber. Patients >65years may be appropriately managed at lower levels (0.4mmol/L- 0.8mmol/L). Lithium carbonate 200mg is equivalent to lithium citrate 509mg.
General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.

History Notes

09/04/2024

Addition of link to general notes on prescribing in pregnancy, ERWG May 24.

27/10/2022

East Region Formulary content agreed.

Dose adjusted according to serum-lithium concentration, doses are initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilised.
Body-weight up to 50kg, initially 520mg twice daily.
Body-weight 50kg and above, initially 1.04-3.12g daily in 2 divided doses.

Olanzapine has a potential to cause weight gain, prescribers should be aware of this and discuss with patients.

10mg daily adjusted to usual range of 5-20mg daily, doses greater than 10mg only after reassessment, max 20mg daily.

Not suitable for females of childbearing potential. Prior to starting valproate, 2 specialists should independently consider and document that there is no other effective or tolerated treatment for all patients (male and female) aged under 55 years, or that there are compelling reasons that the reproductive risks do not apply. See prescribing notes for link to MHRA guidance.

Dose as per specialist.

Not suitable for females of childbearing potential. Prior to starting valproic acid, 2 specialists should independently consider and document that there is no other effective or tolerated treatment for all patients (male and female) aged under 55 years, or that there are compelling reasons that the reproductive risks do not apply. See prescribing notes for link to MHRA guidance.

Dose as per specialist.

Prescribing Notes:

See local guidelines and local shared care protocols, for advice on monitoring, side-effects, drug interactions and psychiatric review.
If a patient has responded to an antipsychotic in the acute phase of bipolar disorder, consideration should be given to continuing this antipsychotic.
Lithium dose is adjusted to achieve a serum lithium concentration within the therapeutic range stated for that individual patient (see Lithium Treatment Plan). If aiming for a different therapeutic range from the normal 0.6-1mmol/L, then this must be clearly communicated to the prescriber. Patients >65years may be appropriately managed at lower levels (0.4mmol/L- 0.8mmol/L). Lithium carbonate 200mg is equivalent to lithium citrate 509mg.
Abrupt withdrawal of lithium may precipitate an episode; all mood stabilisers should be withdrawn over a period of weeks.
Different lithium preparations vary widely in lithium content and bioavailability. The brand name should therefore be specified; a change in the preparation used requires the same precautions as initiation of treatment i.e. weekly monitoring until stable. Note that non-modified-release formulations (Essential Pharma and lithium citrate liquid) should be given twice daily.
Lithium interacts with lots of commonly used medicines. Care should be taken when starting any new medicine in a patient taking lithium. For example, NSAIDs reduce the excretion of lithium causing toxic levels.
Consider quetiapine as a maintenance instead of olanzapine.
Females receiving mood stabilisers must be warned to obtain pre-conceptional advice if they plan to become pregnant; the risk of relapse following withdrawal of mood stabilisers must be balanced against their established teratogenic potential which should be fully discussed with the patient. Psychiatric advice should be sought regarding the most appropriate management of individual patients.
Prior to starting valproate or valproic acid, 2 specialists should independently consider and document that there is no other effective or tolerated treatment for all patients (male and female) aged under 55 years, or there are compelling reasons that the reproductive risks do not apply.
Sodium valproate or valproic acid should never be started in any females unless alternative treatments are not suitable, including in young females below the age of puberty.
Sodium valproate or valproic acid must not be used in any females able to have children unless patient has a pregnancy prevention programme in place. This includes the completion of a signed risk acknowledgement form for female patients starting valproate and at annual review.
Females with childbearing potential must use highly effective contraception if they are able to become pregnant.
Sodium valproate is contra-indicated for bipolar disorder during pregnancy.
A retrospective observational study has been indicated a possible association between valproate use in males around the time of contraception and an increased risk of neurodevelopmental disorders in their children. As a precaution, male patients taking valproate and their partners are recommended to use effective contraception during valproate treatment and for at least 3 months after stopping valproate. Where the decision is taken to initiate valproate in male patients, a signed risk acknowledgement form for male patients must be completed.
Refer to MHRA guidance on valproate to obtain risk materials including pregnancy prevention materials for a specific brand of valproate or valproic acid. See external links to the eMC (SPC & patient leaflets) found next to the medicines choices above, or access the eMC website valproate search and click on “Risk Materials” next to that medicine.
Therapy should be initiated by a specialist and only following medical examination and careful assessment of risk/benefit.
Long-term treatment of bipolar disorder should continue for at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.
The full prophylactic effect of lithium may not occur for six to twelve months after the initiation of therapy.
Due to differences in bioavailability, lithium products are not interchangeable therefore should be prescribed by brand name.
The need for continued lithium therapy should be assessed regularly. Patients on continuous lithium treatment should be assessed by a secondary care specialist at least every 2 years.
General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.

History Notes

07/11/2024

Updated prescribing information, MHRA DSU 5 Sept 24.

27/06/2024

Updated prescribing information, MHRA DSU 28 Nov 23.

09/04/2024

Addition of link to general notes on prescribing in pregnancy, ERWG May 24.

27/10/2022

East Region Formulary content agreed.

View all

Olanzapine has a potential to cause weight gain, prescribers should be aware of this and discuss with patients.

Dose as per specialist and BNFc.

Use an alternative antipsychotic from the first line treatment choices.

Consider adding lithium if an antipsychotic alone is not sufficiently effective. Lithium carbonate 200mg is equivalent to lithium citrate 509mg.

Dose as per specialist and BNFc.

Prescribing Notes:

Mood stabilisers may also be used, either alone or in combination with an antipsychotic, especially for less severe cases.
Antidepressants should be withdrawn if they are thought to contribute to the mania.
See local protocols for advice on monitoring, side-effects, drug interactions and psychiatric review.
Primary treatment for mania is with an antipsychotic agent. If an antipsychotic is ineffective, consider switching to a trial of a different antipsychotic.
Therapy should be initiated by a specialist and only following medical examination and careful assessment of risk/benefit.
Lithium dose is adjusted to achieve a serum lithium concentration within the therapeutic range stated for that individual patient (see Lithium Treatment Plan). If aiming for a different therapeutic range from the normal 0.6-1mmol/L, then this must be clearly communicated to the prescriber. Lithium carbonate 200mg is equivalent to lithium citrate 509mg.
Abrupt withdrawal of lithium may precipitate an episode; all mood stabilisers should be withdrawn gradually. If a patient is unlikely to be compliant, then an alternative to lithium should be considered.
Benzodiazepine may be used for short term use only as per specialist recommendation.

History Notes

15/01/2024

East Region Formulary content agreed.

Continue the existing antipsychotic for 6 months.

Olanzapine has a potential to cause weight gain, prescribers should be aware of this and discuss with patients.

Dose as per specialist and BNFc.

Use an alternative antipsychotic from the first line treatment choices, or Lurasidone monotherapy for 12-17 year olds.

Dose as per specialist and BNFc.

Lithium carbonate 200mg is equivalent to lithium citrate 509mg.

Dose as per specialist and BNFc.

Prescribing Notes:

See local guidelines and local shared care protocols, for advice on monitoring, side-effects, drug interactions and psychiatric review.
Lithium dose is adjusted to achieve a serum lithium concentration within the therapeutic range stated for that individual patient (see Lithium Treatment Plan). If aiming for a different therapeutic range from the normal 0.6-1mmol/L, then this must be clearly communicated to the prescriber.
Abrupt withdrawal of lithium may precipitate an episode; all mood stabilisers should be withdrawn over a period of weeks.
Different lithium preparations vary widely in lithium content and bioavailability. The brand name should therefore be specified; a change in the preparation used requires the same precautions as initiation of treatment i.e. weekly monitoring until stable. Note that non-modified-release formulations (Essential Pharma and lithium citrate liquid) should be given twice daily.
Lithium interacts with lots of commonly used medicines. Care should be taken when starting any new medicine in a patient taking lithium. For example, NSAIDs reduce the excretion of lithium causing toxic levels.
Therapy should be initiated by a specialist and only following medical examination and careful assessment of risk/benefit.
Long-term treatment of bipolar disorder should continue for at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.
The full prophylactic effect of lithium may not occur for six to twelve months after the initiation of therapy.
Due to differences in bioavailability, lithium products are not interchangeable therefore should be prescribed by brand name.
The need for continued lithium therapy should be assessed regularly. Patients on continuous lithium treatment should be assessed by a secondary care specialist at least every 2 years.
Patients with learning disability are at increased risk of epilepsy; mood stabilisers should be used with caution and treatment commenced in consultation with a specialist.

History Notes

15/01/2024

East Region Formulary content agreed.

First line treatment is non-pharmacological measures such as psychological interventions (cognitive behavioural therapy or interpersonal therapy).

Dose as per specialist and BNFc.

Olanzapine has a potential to cause weight gain, prescribers should be aware of this and discuss with patients.

Dose as per specialist and BNFc.

History Notes

15/01/2024

East Region Formulary content agreed.