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.