37 - References

References

298 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 2 resulting in treatment failure. Patients requiring contraception should either receive a preparation containing not less than 50mcg oestrogen or use a non-­hormonal method. Drugs that inhibit CYP3A4 will increase carbamazepine plasma levels and may precipitate toxicity. Examples include fluconazole, cimetidine, diltiazem, verapamil, erythromycin and some SSRIs. Pharmacodynamic interactions also occur. The antiseizure activity of carbamazepine is reduced by drugs that lower the seizure threshold (e.g. antipsychotics and antidepressants); the potential for carbamazepine to cause neutropenia may be increased by other drugs that depress the bone marrow function (e.g. clozapine); and the risk of hyponatraemia may be increased by other drugs that have the potential to deplete sodium (e.g. diuretics). Neurotoxicity has very rarely been reported when carbamazepine is used in combination with lithium. As carbamazepine is structurally similar to TCAs, in theory it should not be given within 14 days of discontinuing a monoamine oxidase inhibitor (MAOI). There seems to be no clinical basis to this restriction. Table 2.4 summarises the prescribing and monitoring of carbamazepine. References

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7. Grunze A, et al. Efficacy of carbamazepine and its derivatives in the treatment of bipolar disorder. Medicina (Kaunas) 2021; 57:433. Table 2.4  Carbamazepine: prescribing and monitoring. Indications Mania (not first line), bipolar depression (evidence weak), unipolar depression (evidence weak) and prophylaxis of bipolar disorder (third line after antipsychotics and valproate). Alcohol withdrawal (may be poorly tolerated). Carbamazepine is licensed for the treatment of bipolar illness in patients who do not respond to lithium. Pre-­carbamazepine work-­up U&Es, FBC and LFTs. Baseline measure of weight desirable. HLA genotyping. CYP3A4 genotyping. Prescribing Titrate dose upwards against response and adverse effects; start with 100–­200mg twice a day and aim for 400mg twice a day (some patients will require higher doses). The modified-­release formulation (Tegretol Retard) can be given once to twice daily, is associated with less severe fluctuations in serum levels and is generally better tolerated. Plasma levels can be used to assure adequate dosing and treatment compliance. Blood should be taken immediately before the next dose. Carbamazepine induces its own metabolism. Blood levels should be re-­checked 2 weeks after an increase in dose. Monitoring U&Es, FBC and LFTs yearly and when clinically indicated. Weight (or body mass index). Stopping Reduce slowly over at least 1 month, preferably longer. Hyperbolic tapering has theoretical support.

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