For Bipolar Disorder (3/7, 4 or 7 dys)
| Lithium | ‣ | Carbamazepine | Oxcarbazepine | Lamotrigine |
|---|---|---|---|---|
| Indications | Bipolar disorder, depression | Bipolar disorder | Bipolar disorder | Bipolar disorder |
| Approval in Youth | No | No | No | No |
| Pharmacokinetics | Not metabolised, excreted by kidneys | Phase II 90% (glucuronidation), Phase I 10% | Phase I CYP3A4, 2C19 (autoinducing) | Minimal P450 interactions, does not autoinduce, more favourable side effect profile |
| Monitoring | Lithium levels, kidney function, thyroid function | Epival levels, albumin level, liver function | Carbamazepine level, albumin level, liver function | Oxcarbazepine metabolite level, albumin level, liver function |
| Side Effects | Tremors, acne, thyroid disorders, hypercalcemia | GI issues, weight gain, hair loss, tremor, PCOS, thrombocytopenia, hair loss, encephalopathy, cognitive dulling[2] | Cognitive dulling, diplopia, nystagmus, vertigo, hyponatremia | Cognitive dulling, hyponatremia |
| Adverse Reactions | Renal impairment, nephrotoxicity | Pancreatitis, hepatoxcitity | Agranulocytosis, aplastic anemia, hepatotoxicity, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) | Agranulocytosis, aplastic anemia, hepatotoxicity, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) |
| Teratogen | Ebstein's anomaly (cardiac) | Neural tube defects | Neural tube defects, cleft lip | Neural tube defects, cleft lip |
| Drug-Drug Interactions | ACE inhibitors, angiotensin II receptor antagonists (ARBs), thiazide diuretics, NSAIDs, COX-2 Inhibitors | The combination of VPA with lamotrigine can cause significant and dangerous increases of lamotrigine, due to inhibition of the glucuronidation. | Potent CYP interactions with many drugs. | Many!!! |
| Notes | The gold standard treatment for bipolar disorder. | In bipolar disorder, may be better for those with comorbid substance use, or traumatic brain injuries | In bipolar disorder, may be better for those with comorbid substance use, substance use disorder, or a negative family history of bipolar disorder. | Similar to carbamazepine, but has several advantages, including no autoinduction, and much less CYP P450 enzyme interactions |