Lithium and Valproate in Bipolar Disorder: From International Evidence-based Guidelines to Clinical Predictors

Abstract

Since decades, lithium and valproate remain the pharmacological cornerstone to treat bipolar disorder. Different response patterns occur according to the phases of illness. At same time, individual pretreatment variables may concur to determine a specific drug-response. Our narrative review focuses on these two key clinical aspects to summarize the state of art. Information from i) clinical trials and ii) the most relevant international guidelines is collected to assess the clinical and preclinical factors that may guide the use of lithium rather than valproate. Lithium may be effective in treating acute mania, and lithium efficacy is maximized when used to prevent both manic and depressive episodes. Lithium may be a better treatment choice in patients with: positive family history for bipolar disorder, mania-depression-interval pattern, few previous affective episodes/hospitalizations, high risk for suicide, no comorbidities. Valproate may be more effective as antimanic rather than prophylactic agent. Valproate might be a better choice in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities. Finally, neither lithium nor valproate are suggested for the treatment of acute mixed states or bipolar depression. To consider clinical and preclinical factors may thus be useful to select the best treatment strategy.

Global perspectives on bipolar disorder treatment: in-depth comparative analysis of international guidelines for medication selection

“…Valproate and its formulations are beneficial in treating bipolar disorder, demonstrating efficacy in managing acute mania and mixed episodes, although the existing evidence for its effectiveness in acute depression is more limited than that for lithium; it is also effective in preventing both mania and depression during the maintenance phase. 10 , 12 , 19 …”

Korean Medication Algorithm Project for Bipolar Disorder 2022: Comparisons with Other Treatment Guidelines

“…This result seems to reflect concerns regarding the safety of Li. However, guidelines have also advised that Val should not be used for women of child bearing potential because of its unacceptable risk of teratogenesis and impaired intellectual development of the fetus [ 18 , 21 , 23 , 25 , 48 ].…”

На Крок Попереду Хвороби: Як Покращити Результати Терапії При Біполярному Розладі?

“…Проте використання останнього ускладнюється його вузьким терапевтичним індексом та необхідністю контролювати концентрацію в крові [4]. Останніми роками зростає інтерес до персоналізації використання СН, у тому числі в поєднанні з антипсихотичними препаратами (ААП) (атиповими чи 2-го покоління) у моно-чи комбінованій терапії залежно від стадії перебігу захворювання та клінічних ознак [11]. При цьому щодо вибору конкретних препаратів зазначеної групи між настановами є розбіжності.…”