49 - References

References

312 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 2 References

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5. Huang W, et al. Comparative efficacy, safety, and tolerability of pharmacotherapies for acute mania in adults: a systematic review and network meta-­analysis of randomized controlled trials. Mol Psychiatry 2024; doi: 10.1038/s41380-­024-­02705-­3. Table 2.7  Mania: other possible treatments.* Treatment Comments Allopurinol (300–­600mg/day) A meta-­analysis of five studies of adjunct allopurinol found an effect size of just less than 0.3.50 Celecoxib (400mg/day)51 Small RCT (n = 46) suggests benefit when used as adjunct to valproate. Clonidine (450–­900mcg/day)52 Limited data Clozapine53–­55 Established treatment option for refractory mania/bipolar disorder. Rapid titration has been reported.56 Endoxifen57 (4–­8mg/day) RCT evidence of efficacy. Major metabolite of tamoxifen. Gabapentin58 (up to 2.4g/day) Probably only effective by virtue of an anxiolytic effect. Rarely used. Possibly useful as prophylaxis.59 Levetiracetam (up to 1500mg/day) Effective as adjunctive treatment in two RCTs.60,61 One case of levetiracetam causing mania.62 Melatonin (6mg/day)67 Preliminary evidence of benefit as an adjunct to standard treatment. One small negative study.68 Memantine63 (10–­30mg/day) Conflicting evidence64–­66 Oxcarbazepine69–­76 (around 300–­3000mg/day) Probably effective acutely and as prophylaxis although one controlled study (conducted in youths) was negative.77 Phenytoin78 (300–­400mg/day) Rarely used. Limited data. Complex kinetics with narrow therapeutic range. Ritanserin79 (10mg/day) Supported by a single RCT. Well tolerated. May protect against EPSEs. Tamoxifen80 (20–­140mg/day) Good evidence for efficacy as adjunct and as monotherapy, with large effect size. May provoke switch to depression. Topiramate81 (up to 300mg/day) Probably not effective. Less effective than lithium.2 Tryptophan depletion82 Supported by a small RCT. Ziprasidone83–­85 Supported by three RCTs. Widely used outside UK. *Entries are given in alphabetical order; no preference is implied by order in the table. Consult specialist and primary literature before using any treatment listed. EPSEs, extrapyramidal side effects; RCT, randomised controlled trial.

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