Lithium is the most frequently used agent for bipolar disease but it has a very narrow therapeutic index. Lithium is formulated as a chemical salt, of which lithium carbonate is the most commonly prescribed (citrate, sulfate, orotate are alternatives). Dosing is BID or TID. Therapeutic trough levels are typically 1.0-1.5 mEq/l for acute mania and 0.6-1.2 mEq/l for chronic maintenance. Regular serum lithium level testing is necessary. Important to monitor renal and thyroid function. Can be used in the treatment of cluster headache syndromes.
Valproic acid (Depakote®®): GABA transaminase inhibitor as well as inhibitor of voltage-gated sodium channels and T-type calcium channels. Valproate is a known folate antagonist, which can cause neural tube defects, so avoid in pregnancy if possible.
Carbamazepine (Tegretol®®): previously discussed under "Anticonvulsants." Lamotrigine (Lamictal®®): previously discussed under "Anticonvulsants."
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