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Butler M, Urosevic S, Desai P, et al. Treatment for Bipolar Disorder in Adults: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Aug. (Comparative Effectiveness Review, No. 208.)

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Treatment for Bipolar Disorder in Adults: A Systematic Review [Internet].

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Appendix QHarms Tables

Appendix Table Q1FDA box warnings for drugs used for bipolar treatment

DrugBox Warning
AripiprazoleIncreased mortality in elderly patients with dementia related psychosis. IRisk of suicide among adolescents.
AsenapineIncreased mortality In elderly patients with dementia related psychosis.
CarbamazepineRisk of suicide.

Serious, sometimes fatal dermatologic reactions reported, including toxic epidermal necrolysis and Stevens-Johnson syndrome. Risk 10x greater in some Asian countries; strong associated between risk and HLA-B*1502 allele, which is found almost exclusively in Asian patients.

Transient or persistent decreased platelet or white blood cell counts not uncommon with carbamazepine but majority of leukopenia cases do not progress to aplastic anemia or agranulocytosis. Perform baseline and periodic hematological testing. Consider discontinuing treatment if evidence of significant bone marrow depression.
CariprazineIncreased mortality In elderly patients with dementia related psychosis.
LamotrigineRisk of suicide.

Serious skin rashes.
LithiumLithium toxicity can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy.
OlanzapineIncreased mortality In elderly patients with dementia related psychosis. When used in combination with fluoxetine also warn against suicidality and antidepressant drugs.
QuetiapineIncreased mortality in elderly patients with dementia related psychosis. Risk of suicide among adolescents.
RisperidoneIncreased mortality In elderly patients with dementia related psychosis.
Valproic acid/valproate/divalproex (same for all)Risk of suicide.

Serious or fatal hepatotoxicity has occurred, usually during first six months of treatment. Patients <2 years old are at increased risk, especially with the following comorbidities: multiple anticonvulsant treatment, congenital metabolic disorder, severe seizure disorder with mental retardation, or organic brain disorders.

Increased risk of acute liver failure and death in patients with hereditary neurometabolic syndromes caused by mitochondrial DNA polymerase gamma gene mutations (e.g. Alpers Huttenlocher Syndrome).

Fetal risk via major congenital malformations including neural tube defects and decreased IQ scores after in utero exposure.

Life threatening pancreatitis including hemorrhagic cases with rapid progression from initial symptoms to death reported in children and adults.
ZiprasidoneIncreased mortality In elderly patients with dementia related psychosis.
AllopurinolNone
BupropionRisk of suicide among adolescents.

Serious neuropsychiatric events have been reported in patients taking bupropion for smoking cessation.
CelecoxibMay cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, particularly in elderly patients.
CitalopramRisk of suicide among adolescents.
DipyridamoleNone
DonepezilNone
FluoxetineRisk of suicide among adolescents.
GabapentinRisk of suicide.
HaloperidolIncreased mortality In elderly patients with dementia related psychosis.
MemantineNone
OxcarbazepineRisk of suicide.
PaliperidoneIncreased mortality In elderly patients with dementia related psychosis.
ParoxetineRisk of suicide among adolescents.
PerphenazineIncreased mortality In elderly patients with dementia related psychosis.
RamelteonNone
TamoxifenWomen with ductal carcinoma in situ and at high risk for breast cancer at increased risk of uterine malignancies, stroke and pulmonary embolism.
TopiramateRisk of suicide.
VenlafaxineRisk of suicide among adolescents.
VerapamilNone

Sources:

Abbreviations: FDA=United States Food and Drug Administration

Appendix Table Q2Previously reported side effects* of bipolar medications

Drug
Generic Name (Trade Names)
Side Effects
Aripiprazole (Ability)1
  • Cardiovascular: Cardiorespiratory arrest (0.1% to 1%), Cardiorespiratory failure (0.1% to 1%), Myocardial infarction (0.1% to 1%), Prolonged QT interval (0.1% to 1%)
  • Endocrine metabolic: Diabetic ketoacidosis (Less than 0.1%)
  • Gastrointestinal: Pancreatitis
  • Hematologic: Agranulocytosis, Leukopenia (Less than 1%), Neutropenia (Less than 1%)
  • Musculoskeletal: Rhabdomyolysis (Less than 0.1%)
  • Neurologic: Cerebrovascular accident, Seizure (Up to 0.3%), Tardive dyskinesia, Transient ischemic attack
  • Psychiatric: At risk for suicide, Suicidal behavior
  • Other: Angioedema (0.1% to less than 1%), Increased body temperature, Neuroleptic malignant syndrome
  • Neurologic: Akathisia (2% to 25%), Dizziness (4% to 10%), Extrapyramidal sign (2% to 27.3%), Headache (10% to 27%), Insomnia (8% to 18%), Sedated (3% to 21%), Somnolence (6% to 26.3%), Tremor (2% to 11.8%)
Asenapine (Saphris)1
  • Cardiovascular: Prolonged QT interval
  • Endocrine metabolic: Hyperglycemia (Adult, 1.7% to 15.8%; pediatric up to 1.8%), Serum cholesterol abnormal (Adult, 0% to 14.7%; pediatric, 0% to 9.6%), Serum triglycerides raised, Or altered (Adult, 1.6% to 8.3%; pediatric, 1.9% to 4%), Weight increased (Adult, 1% to 22%; pediatric, 2% to 12%)
  • Hematologic: Agranulocytosis, Decreased blood leukocyte number, Neutropenia
  • Immunologic: Hypersensitivity reaction
  • Neurologic: Somnolence (Adult, 13% to 26%; pediatric, 46% to 53%)
  • Psychiatric: Suicidal thoughts (1% to 4%)
  • Other: Angioedema, Death, Neuroleptic malignant syndrome
  • Neurologic: Akathisia (Adult, 4% to 15%; pediatric, 1% to 2%), Dizziness (Adult, 3% to 8%; pediatric, 5% to 10%), Extrapyramidal disease (6% to 12%)
Carbamazepine (Carbetrol, Epitol, Equetro, Tegretol, Teril)1
  • Cardiovascular: Atrioventricular block, Cardiac dysrhythmia, Congestive heart failure, Eosinophilic myocarditis, Hypersensitivity, Syncope
  • Dermatologic: Stevens-Johnson syndrome, Toxic epidermal necrolysis
  • Endocrine metabolic: Hypocalcemia, Hyponatremia (Oral, 4% to 21.7%; IV, less than 2%), Water intoxication syndrome
  • Gastrointestinal: Pancreatitis
  • Hematologic: Agranulocytosis, Aplastic anemia, Bone marrow depression, Eosinophil count raised, Leukopenia, Pancytopenia, Thrombocytopenia
  • Hepatic: Hepatitis, Liver damage, Liver failure, Vanishing bile duct syndrome
  • Immunologic: Drug reaction with eosinophilia and systemic symptoms
  • Neurologic: Acute intermittent porphyria
  • Renal: Azotemia, Renal failure
  • Respiratory: Pulmonary hypersensitivity
  • Other: Angioedema
  • Neurologic: Asthenia (8%), Ataxia (15%), Dizziness (Bipolar disorder, 44%; seizures, 9%), Somnolence (Bipolar disorder, 32%; seizures, 5%)
Cariprazine (Vraylar)1
  • Cardiovascular: Ischemic stroke (Up to 0.1%), Orthostatic hypotension
  • Endocrine metabolic: Diabetes mellitus, Dyslipidemia, Hyperglycemia
  • Gastrointestinal: Esophageal dysmotility
  • Hematologic: Leukopenia, Neutropenia
  • Musculoskeletal: Tardive dyskinesia
  • Neurologic: Seizure
  • Psychiatric: At risk for suicide (Up to 1%), Loss of judgement
  • Respiratory: Pulmonary aspiration
  • Other: Body temperature finding, Body temperature dysregulation, Neuroleptic malignant syndrome
  • Neurologic: Akathisia (Schizophrenia, 9%; bipolar, 20%), Extrapyramidal sign (Schizophrenia, 15%; bipolar, 26%), Somnolence (5% to 8%)
Lamotrigine (Lamictal)1
  • Dermatologic: Erythema multiforme (less than 0.1%), Rash, Serious (0.08% to 0.8%), Stevens-Johnson syndrome, Toxic epidermal necrolysis
  • Hematologic: Anemia (immediate release, less than 0.1%), Disseminated intravascular coagulation, Eosinophil count raised (immediate release, less than 0.1%), Leukopenia (immediate release, 0.1% to 1%), Thrombocytopenia (immediate release, less than 0.1%)
  • Hepatic: Liver failure
  • Immunologic: Drug reaction with eosinophilia and systemic symptoms
  • Neurologic: Aseptic meningitis
  • Other: Angioedema (less than 0.1%), Neuroleptic malignant syndrome
  • Neurologic: Asthenia (immediate-release, 2% to 8%; extended-release, 6%), Ataxia (immediate-release, 2% to 11%), Coordination problem (immediate-release, 6% to 7%; extended-release, 3%), Dizziness (immediate-release, 7% to 54%; extended release, 14%), Headache (immediate-release, 29%), Insomnia (immediate-release, 5% to 10%), Somnolence (immediate-release, 9% to 17%; extended-release, 5%), Tremor (immediate-release, 4% to 10%; extended-release, 6%), Vertigo (immediate-release, 2%; extended-release, 3%)
Lithium3
  • Black Box Warning: Lithium toxicity can occur at doses close to therapeutic levels. Keep all appointments to check response to lithium.
  • unusual tiredness or weakness
  • excessive thirst
  • frequent urination
  • slow, jerky movements
  • movements that are unusual or difficult to control
  • blackouts
  • seizures
  • fainting
  • dizziness or lightheadedness
  • fast, slow, irregular, or pounding heartbeat
  • shortness of breath
  • chest tightness
  • confusion
  • hallucinations (seeing things or hearing voices that do not exist)
  • crossed eyes
  • painful, cold, or discolored fingers and toes
  • headache
  • pounding noises inside the head
  • swelling of the feet, ankles, or lower legs
Olanzapine (Zyprexa)1
  • Cardiovascular: Sudden cardiac death
  • Endocrine metabolic: Diabetes mellitus, Diabetic coma with ketoacidosis, Diabetic ketoacidosis, Hyperglycemic hyperosmolar state
  • Gastrointestinal: Acute hemorrhagic pancreatitis
  • Hematologic: Leukopenia, Venous thromboembolism
  • Immunologic: Drug reaction with eosinophilia and systemic symptoms, Hypersensitivity reaction
  • Neurologic: Cerebrovascular disease, Dystonia (2% to 3%), Seizure (0.9%), Status epilepticus
  • Psychiatric: Suicidal intent (0.1% to 1%)
  • Respiratory: Pulmonary embolism
  • Neurologic: Akathisia (5% to 27%), Asthenia (2% to 20%), Dizziness (Adult, 1.6% to 18%; adolescent, 7% to 8%), Somnolence (IM, 6%; oral, 20% to 52%), Tremor (1% to 23%)
Quetiapine2 (Seroquel)
Risperidone (Risperdal)1
  • Cardiovascular: Prolonged QT interval, Sudden cardiac death, Syncope (oral, up to 1%; IM, up to 2%)
  • Endocrine metabolic: Diabetic ketoacidosis, Hypothermia
  • Gastrointestinal: Pancreatitis
  • Hematologic: Agranulocytosis, Leukopenia, Neutropenia, Thrombocytopenia, Thrombotic thrombocytopenic purpura
  • Neurologic: Cerebrovascular accident, Seizure (0.3%), Tardive dyskinesia (oral, less than 5%; IM, less than 4%)
  • Reproductive: Priapism
  • Respiratory: Pulmonary embolism
  • Other: Neuroleptic malignant syndrome
  • Neurologic: Akathisia (oral, up to 10%; IM, 4% to 11%), Dizziness (oral, 4% to 16%; IM, 3% to 11%), Dystonia (oral, adult, 3% to 5%; pediatric, 2% to 6%; IM, adult, less than 4%), Parkinsonism (oral, 6% to 28%; IM, 8% to 15%), Sedated (5% to 63%), Tremor (oral, 2% to 12%; IM, 3% to 24%)
Valproic acid (Depakene, Stavzor, Valproic)1
  • Cardiovascular: Palpitations (1% to less than 5%), Tachycardia (1% to less than 5%)
  • Endocrine metabolic: Hyperammonemia
  • Gastrointestinal: Hematemesis (1% to less than 5%)
  • Hematologic: Myelodysplastic syndrome, Thrombocytopenia, Dose-related (1% to 27%)
  • Immunologic: Hypersensitivity reaction (rare)
  • Neurologic: Coma, Hyperammonemia-induced, Encephalopathy, Hyperammonemic encephalopathy
  • Otic: Ototoxicity - deafness (1% to less than 5%)
  • Respiratory: Pleural effusion (rare) Neurologic: Amnesia (4% to 7%), Asthenia (10% to 27%), Ataxia (8%), Dizziness (12% to 25%), Headache (5% to 31%), Insomnia (9% to 15%), Somnolence (17% to 30%), Tremor (9% to 57%)
  • Neurologic: Amnesia (4% to 7%), Asthenia (10% to 27%), Ataxia (8%), Dizziness (12% to 25%), Headache (5% to 31%), Insomnia (9% to 15%), Somnolence (17% to 30%), Tremor (9% to 57%)
Divalproex (Depakote)1
  • Cardiovascular: Palpitations (greater than 1% to less than 5%), Tachycardia (greater than 1% to less than 5%)
  • Endocrine metabolic: Hyperammonemia
  • Gastrointestinal: Pancreatitis (greater than 1% to less than 5%)
  • Hematologic: Myelodysplastic syndrome, Thrombocytopenia, Dose-related (1% to 27%)
  • Hepatic: Liver failure
  • Immunologic: Drug reaction with eosinophilia and systemic symptoms (rare)
  • Neurologic: Hyperammonemic encephalopathy
  • Otic: Ototoxicity - deafness (greater than 1% to less than 5%)
  • Neurologic: Asthenia (6% to 27%), Dizziness (up to 25%), Feeling nervous (up to 11%), Headache (31%), Insomnia (up to 15%), Somnolence (Adult, 7% to 30%; pediatric, greater than 5%), Tremor (1% to 57%)
Valproate (Depacon)1
  • Endocrine metabolic: Hyperammonemia
  • Gastrointestinal: Pancreatitis
  • Hematologic: Myelodysplastic syndrome, Thrombocytopenia (27%)
  • Hepatic: Liver failure
  • Immunologic: Drug reaction with eosinophilia and systemic symptoms
  • Neurologic: Hyperammonemic encephalopathy
Ziprasidone3 (Geodon)
Allopurinol1 (Aloprim, Zyloprim)
  • Dermatologic: Drug reaction with eosinophilia and systemic symptoms, Rash (up to 3%), Stevens-Johnson syndrome (less than 1%), Toxic epidermal necrolysis (less than 1%)
  • Hematologic: Agranulocytosis, Aplastic anemia, Eosinophil count raised, Myelosuppression, Thrombocytopenia (0.6%)
  • Hepatic: Granulomatous hepatitis (less than 1%), Hepatic necrosis (less than 1%), Hepatotoxicity
  • Immunologic: Hypersensitivity reaction
  • Renal: Renal failure (less than 1%)
Bupropion2 (Aplenzin, Wellbutrin, Zyban)
Celecoxib (Celebrex)1
  • Cardiovascular: Myocardial infarction (Osteoarthritis or rheumatoid arthritis, 0.1% to 1.9%), Torsades de pointes, Ventricular hypertrophy (familial adenomatous polyposis, 0.1% to 1%)
  • Dermatologic: Erythema multiforme, Erythroderma, Generalized exanthematous pustulosis, acute, Stevens-Johnson syndrome, Toxic epidermal necrolysis
  • Endocrine metabolic: Hyperkalemia
  • Gastrointestinal: Gastrointestinal hemorrhage (Osteoarthritis or rheumatoid arthritis, less than 0.1%), Gastrointestinal perforation (Osteoarthritis or rheumatoid arthritis, less than 0.1%), Gastrointestinal ulcer, Inflammatory disorder of digestive tract
  • Hematologic: Hemorrhage, Thrombosis (familial adenomatous polyposis, 1.2%)
  • Hepatic: Fulminant hepatitis, Hepatotoxicity (Rare), Increased liver enzymes (Osteoarthritis or rheumatoid arthritis, 0.1% to 1.9%), Liver failure
  • Immunologic: Anaphylactoid reaction, Drug reaction with eosinophilia and systemic symptoms
  • Neurologic: Cerebrovascular accident
  • Renal: Acute renal failure, Injury of kidney
  • Respiratory: Asthma, Bronchospasm (arthritis, 0.1% to 1.9%)
Citalopram2 (Celexa)
Dipyridamole (Persantine)1
  • Cardiovascular: Angina pectoris, Cardiac arrest, Myocardial infarction (IV, 0.1%), Myocardial ischemia, Ventricular fibrillation, Ventricular tachycardia (IV, 0.2%)
  • Hepatic: Liver failure
  • Immunologic: Hypersensitivity reaction
  • Neurologic: Cerebrovascular accident, Seizure
  • Respiratory: Bronchospasm (IV, 0.2%)
Donepezil2 (Aricept)
Fluoxetine2 (Prozac, Sarafem)
Gabapentin (Gralise, Horizant, Neurontin)1
  • Dermatologic: Stevens-Johnson syndrome
  • Endocrine metabolic: Hypoglycemia
  • Immunologic: Anaphylaxis, Drug reaction with eosinophilia and systemic symptoms
  • Neurologic: Dizziness (Adults, 28%; adults and adolescents, 17%; pediatrics, 3%), Somnolence (Adults, 21%; adults and adolescents, 19%; pediatrics, 8%)
  • Psychiatric: Disorder of form of thought (Pediatric, 1.7%), Disturbance in thinking (2% to 3%), Hostile behavior (Pediatric, 5.2%), Hyperactive behavior (Pediatric, 4.7%), Mood swings (Pediatric, 6%), Suicidal thoughts
  • Other: Angioedema
  • Neurologic: Ataxia (Adult, 3%; adult and adolescent, 13%), Nystagmus (Adult and adolescent, 8%)
Haloperidol (Haldol)1
  • Cardiovascular: Prolonged QT interval, Sudden cardiac death, Torsades de pointes
  • Gastrointestinal: Paralytic ileus
  • Hematologic: Agranulocytosis
  • Neurologic: Dystonia, Neuroleptic malignant syndrome, Seizure, Tardive dyskinesia
  • Reproductive: Priapism
  • Neurologic: Akathisia, Extrapyramidal disease (Frequent), Somnolence
Memantine2 (Namenda)
Oxcarbazepine (Trileptal)1
  • Dermatologic: Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis
  • Endocrine metabolic: Hyponatremia (1% to 5%)
  • Hematologic: Agranulocytosis, Leukopenia, Pancytopenia
  • Immunologic: Anaphylaxis, Hypersensitivity reaction, Multiorgan
  • Neurologic: Status epilepticus
  • Psychiatric: Suicidal thoughts
  • Other: Angioedema
  • Neurologic: Abnormal gait (Up to 17%), Ataxia (Adult, 1% to 31%; pediatric, 13%), Dizziness (Adult, 8% to 49%; pediatric, 28%), Headache (Adult, 8% to 32%; pediatric, 31%), Impairment of balance (5% to 7%), Somnolence (Adult, 5% to 36%; pediatric, 31% to 34.8%), Tremor (1% to 16%)
Paliperidone (Invega)1
  • Cardiovascular: Prolonged QT interval (7%)
  • Hematologic: Agranulocytosis, Leukopenia
  • Neurologic: Dysphagia, Tardive dyskinesia
  • Reproductive: Priapism
  • Neurologic: Akathisia (3% to 17%), Dyskinesia (1% to 6%), Dystonia (1% to 14%), Extrapyramidal disease (4% to 23%), Parkinsonism (Up to 14%), Somnolence (6% to 26%), Tremor (2% to 12%)
Paroxetine2 (Brisdelle, Paxil, Pexeva)
Perphenazine (Trilafon)1
  • Cardiovascular: Prolonged QT interval, Torsades de pointes
  • Gastrointestinal: Obstipation (rare), Paralytic ileus (rare)
  • Hematologic: Agranulocytosis (rare), Disorder of hematopoietic structure (rare), Leukopenia (rare), Thrombocytopenia (rare)
  • Immunologic: Drug-induced lupus erythematosus, Systemic (rare)
  • Neurologic: Ineffective thermoregulation, Heatstroke or hypothermia (rare), Neuroleptic malignant syndrome (rare), Seizure (rare)
  • Reproductive: Priapism (rare)
  • Other: Death
  • Neurologic: Akathisia, Dizziness, Drug-induced tardive dystonia, Dystonia, Extrapyramidal disease, Parkinsonian, Somnolence, Tardive dyskinesia
Ramelteon (Rozerem)1
  • Psychiatric: Depression, worsening, Hallucinations, Mania
  • Other: Angioedema (rare)
Tamoxifen2 (Nolvadex, Soltamox)
  • Chest pain, shortness of breath, or coughing up blood.
  • Dark-colored urine or pale stools.
  • Fever, chills, cough, sore throat, and body aches.
  • Heavy or abnormal vaginal bleeding, pelvic pain or pressure.
  • Nausea, vomiting, loss of appetite, or pain in your upper stomach.
  • New breast lumps.
  • Numbness or weakness in your arm or leg, or on one side of your body.
  • Pain in your lower leg (calf).
  • Sudden or severe headache, or problems with vision, speech, or walking.
  • Swelling in your hands, ankles, or feet.
  • Unusual bleeding, bruising, or weakness.
  • Yellowing of your skin or the whites of your eyes.
Topiramate (Qudexy, Topamax)1
  • Dermatologic: Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis
  • Endocrine metabolic: Hyperammonemia (Adolescents, 26%), Hypohidrosis, Increased body temperature, Metabolic acidosis (Adult, 14% to 44%; pediatric, 9% to 77%)
  • Hepatic: Liver failure
  • Neurologic: Drug-induced encephalopathy
  • Ophthalmic: Angle-closure glaucoma, Glaucoma, Myopia, Visual field defect (epilepsy, 0.1% to 1%)
  • Psychiatric: Suicidal thoughts
  • Renal: Nephrolithiasis (adults, 1% to 3%)
  • Other: Withdrawal sign or symptom
  • Neurologic: Confusion (3% to 11%), Dizziness (4% to 25%), Impaired cognition (2% to 7%), Impaired psychomotor performance (2% to 13%), Memory impairment (3% to 12%), Paresthesia (1% to 51%), Reduced concentration span (2% to 10%), Somnolence (6% to 29%)
Venlafaxine2 (Effexor)
  • Anxiety, restlessness, fever, sweating, muscle spasms, nausea, vomiting, diarrhea, seeing or hearing things that are not there
  • Blistering, peeling, red skin rash
  • Chest pain, cough, trouble breathing
  • Confusion, weakness, and muscle twitching
  • Eye pain, vision changes, seeing halos around lights
  • Fast or pounding heartbeat
  • Feeling more excited or energetic than usual
  • Headache, trouble concentrating, memory problems, unsteadiness
  • Seizures
  • Unusual behavior, thoughts of hurting yourself or others, trouble sleeping, nervousness, unusual dreams
  • Unusual bleeding or bruising
Verapamil2 (Calan, Covera-HS, Verelan)
*

We did not differentiate between mild/moderate versus serious side effects.

Sources:

1
2
3

Abbreviations: BP=bipolar disorder; FDA=United States Food and Drug Administration

Bookshelf ID: NBK532169

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