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Eur Neuropsychopharmacol. 2019 Oct 4. pii: S0924-977X(19)30881-8. doi: 10.1016/j.euroneuro.2019.09.007. [Epub ahead of print]

Expert advice on the management of valproate in women with bipolar disorder at childbearing age.

Author information

1
Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel st, 12-0, 08036, Barcelona, Catalonia, Spain.
2
Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, 7 Dębinki St., 80-952 Gdańsk, Poland.
3
Department of Psychiatry, Jagiellonien University Collegium Medicum, Kopernika 21a st, 31-501 Cracow, Poland.
4
Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy and San Luigi Gonzaga University Hospital.
5
University Lille, CNRS UMR 9193-PsyCHIC-SCALab, and CHU Lille, Pôle de Psychiatrie, F-59000 Lille, France.
6
Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel st, 12-0, 08036, Barcelona, Catalonia, Spain. Electronic address: evieta@clinic.cat.

Abstract

INTRODUCTION:

The perinatal period is associated with up to 2/3 relapses in untreated bipolar disorder (BD), with important consequences on the clinical BD outcome and on fetal and child development. Valproate (VPA), one of the most effective treatments in BD, is associated with the highest risk of serious neurodevelopmental disorders in exposed children. This has brought to tightened restrictions to its use by regulatory agencies and clinical guidelines.

METHODS:

A panel of experts on the pharmacological treatment of BD conducted a non-systematic review of the scientific literature and clinical guidelines until March 2019, and provided specific evidence-based and experience-based clinical recommendations for VPA switching/discontinuation in BD women of childbearing potential.

RESULTS:

After the review of the evidence in a face-to-face meeting, the panel concluded that several clinical criteria need to be considered to make a clinical decision about VPA discontinuation and switch. The plateau cross-taper switch may be preferred. Abrupt switching may bear augmented risk of relapse CONCLUSIONS: BD childbearing women treated with VPA must be managed on a personalized basis according to the clinical situation. It is mandatory to stop VPA during pregnancy. The duration of the discontinuation/switch process depends on different clinical variables. Lithium, lamotrigine, quetiapine, olanzapine or aripiprazole are good options for switch in stable BD patients in planned/unplanned pregnancy. In unstable BD patients planning pregnancy, stability is paramount. Prevention of post-partum episodes requires reinstatement of effective treatment before or after birth (in the case of VPA). VPA is still an option in the post-partum period and beyond.

KEYWORDS:

Bipolar; Childbearing; Guidelines; Perinatal; Switch; Valproate

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