Table 4:
Dose adjustment for hepatic and renal impairment of medications used for
treatment of bipolar disorder.
Medication |
Metabolism site |
Metabolism pathway |
Dose adjustment for Hepatic Impairment |
Dose adjustment for Renal Impairment |
Drug-drug interactions with immunosuppressants,
or prophylactic antimicrobials |
Mood
Stabilizers: Lithium |
Kidney |
|
None |
GFR > 50 ml/min:
None GFR 10 - 50 ml/min:
reduce dose by 25 - 50% GFR < 10 ml/min:
reduce dose by 50 - 75% |
None |
Anticonvulsants: Valproic Acid |
Liver |
Conjugation |
Do not use with
hepatic disease. |
None |
Decreased valproic acid plasma concentrations and potential
increased seizure activity with acyclovir. |
Lamotrigine |
Liver |
Conjugation |
Moderate-severe
impairment without ascites: reduce dose by 25%. Severe impairment
with ascites: reduce dose by 50%. |
No formal
recommendations; may need to reduce maintenance dose for severe renal
impairment |
None |
Atypical
Antipsychotics: Aripiprazole |
Liver |
CYP2D6,CYP3A4 |
None |
None |
None |
Risperidone |
Liver |
CYP2D6 |
Initial dose: 0.5 mg
ORALLY twice daily; increase dose in increments of no more than 0.5 mg twice
a day, with increases to dosages above 1.5 mg twice a day occurring at
intervals of at least 1 week. |
Same as hepatic |
Major interaction
with tacrolimus or fluconazole due to increased
risk of QT prolongation. |
Olanzapine |
Liver |
CYP1A2,CYP2D6 |
None |
None |
Contraindicated with
fluconazole due to increased risk of QT prolongation. |
Quetiapine |
Liver |
CYP3A4, Sulfoxidation, Oxidation |
Initial dose: 25
mg/day; increase dose daily in increments of 25 to 50 mg/day to an effective
dose based on response and tolerability. |
None |
Contraindicated with
fluconazole and major interaction with tacrolimus
due to increased risk of QT prolongation. |
Ziprasidone |
Liver |
CYP3A4,CYP1A2,
Oxidation, Reduction, Methylation |
None |
None |
Contraindicated with
fluconazole and contraindicated with tacrolimus due
to increased risk of QT prolongation. |