Selected Medications for Bipolar Disorder*
Medication | Indication | Starting Dose† | Maintenance Dose† | Comments |
|---|---|---|---|---|
≥ 12 years | Acute mania and maintenance | — | 450–900 mg twice a day | Dose titrated to a blood level of 0.8–1.2 mEq/L (or mmol/L) |
Acute mania and maintenance | 200–300 mg three times a day | 300–600 mg three times a day up to 2400 mg | Maximum daily dose is 40 mg/kg Associated with decreased suicidality, decreased depression, and better psychosocial functioning in children and adolescents with bipolar disorder¶ | |
Antipsychotics | ||||
≥ 10 years | Acute mania Psychosis | 2–5 mg once a day | Up to 30 mg once a day | Limited experience in children |
>10 years | Bipolar mania | 2.5 mg twice a day sublingual | Up to 10 mg twice a day | Tongue numbness and tingling |
> 5 years‡,§ | Acute mania Psychosis | 0.6–1.5 mg/kg every 6 hours up to 200 mg/day | — | Rarely used (in children who do not respond to newer medications) because newer medications have a more favorable adverse effect profile |
> 10 years | Bipolar depression | 20 mg once a day | Up to 80 mg/day | — |
> 13 years§ | Acute mania Psychosis | 2.5–5 mg once a day | Up to 10 mg twice a day | Causes weight gain, which may limit use in some patients |
> 10 years‡,§ | Bipolar depression | 3 mg/25 mg once a day | Up to 12 mg/50 mg once a day | Limited experience in children |
> 12 years ‡,§ | Acute mania Psychosis | 3 mg once a day | Up to 3 mg twice a day | Very limited experience in children |
> 10 years§ | Acute mania Psychosis | 25 mg twice a day | Up to 200 mg twice a day | Causes sedation that may limit dose increases |
> 10 years§ | Acute mania Psychosis | 0.5 mg once a day | Up to 2.5 mg/day | Maintenance dose highly variable Doses up to 6 mg/day have been studied, but they provide no additional benefit and increase risk of neurologic adverse effects |
> 10 years§ | Acute mania Psychosis | 20 mg once a day | Up to 40 mg twice a day | Very limited experience in children |
Anticonvulsants | ||||
Acute mania and mixed episode | 200 mg twice a day | Up to 600 mg twice a day | Metabolic enzyme induction, possibly requiring dose adjustments May cause Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) especially in patients with HLA-B*15:02 genotype (more common in East Asian populations) and maculopapular exanthema (MPE), drug reaction with eosinophilia (DRESS) and SJS/TEN in patients with HLA-A*31:01 genotype (more common in Caucasians and Hispanics) a | |
Divalproex | Acute mania | 5 mg/kg two or three times a day | Up to 10–20 mg/kg three times a day | Dose titrated to a blood level of 50–125 mcg/mL |
Maintenance | 25 mg once a day | Up to 100 mg twice a day | Requires that dosing guidelines in the package insert be followed closely | |
* These medications pose a small but serious risk for a wide variety of major adverse effects. Therefore, benefits must be carefully weighed against potential risks. | ||||
† Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. This table is not a substitute for the full prescribing information. | ||||
‡ These medications have not been studied in children. For dosing in children under 12 years of age, see the prescribing information. | ||||
§ These medications increase the risk of weight gain, negative effects on the lipid profile, increases in glucose and prolactin levels, and QT prolongation. | ||||
¶ Hafeman DM, Rooks B, Merranko J, et alJ Am Acad Child Adolesc Psychiatry 59(10):1146-1155. doi:https://doi.org/10.1016/j.jaac.2019.06.013 aPhillips EJ, Sukasem C, Whirl-Carrillo, et al: Clinical pharmacogenetics implementation consortium guideline for HLA | ||||