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Indian Journal of Pharmacology, Vol. 38, No. 5, September-October, 2006, pp. 370-371 Case Report Quetiapine monotherapy in long-term mood stabilisation Khazaal Y Department of Psychiatry, Mood and Anxiety Disorders Unit, Echallens 9, 1004 Lausanne Code Number: ph06106 Introduction Quetiapine, an atypical antipsychotic agent, has antagonistic properties towards various neurotransmitter receptor sites, including serotonin (5HT 1A ; 5HT 2A ), dopamine (D 1 ; D 2 ), histamine (H1) and adrenaline (Alpha 1; Alpha 2). Quetiapine has a lower affinity for D 2 receptors than dopamine itself, leading to an intermittent D 2 blockade, and may contribute to the excellent tolerability profile of this substance. It was hypothesised that quetiapine may act on depression, through its antagonism of 5-HT 2A receptors, and on mania through its antagonism of D 2 receptors.[1] Quetiapine was found to be effective in the treatment of acute bipolar mania, both as monotherapy and in combination with other mood stabilisers,[2] as well as monotherapy in acute bipolar depression.[3] Despite this, to our knowledge, there are very few published experiences with regard to long-term quetiapine monotherapy in schizoaffective disorder, bipolar type (SAD) and bipolar disorder (BPD).[4]Case history Ms A, 36 years old, had a 14-year history of SAD with 28 hospitalisations for affective or psychotic episodes (16 manic, 4 depressive episodes, 4 mixed and 4 psychotic episodes). She had no stable accommodation for over 6 months and no stable, significant personal relationships or work during her adult life. She had previously been treated with a number of antipsychotic drugs and mood stabilisers, including lithium, valproate and carbamazepine. Ms A had poor adherence to treatments due to side effects (i.e. loss of hair with valproate, weight gain with lithium) and consistent denial of treatment efficacy. The two years prior to quetiapine treatment were characterised by the worsening of her illness (6 hospitalisations, 198 days). During a manic episode 26 months ago, characterised by elevated mood, irritability, paranoid delusions and aggressive behaviour (mania with psychotic symptoms), quetiapine was introduced for the first time and titrated up to 600 mg twice daily, over two weeks, in association with lorazepam 15 mg/day. No other mood stabilising agent was prescribed, due to patient refusal. Ms A responded well within 8 weeks [Bech-Rafaelsen Mania Scale (MAS) at entry 36, MAS at discharge 5]. She did not have any subsequent depressive episodes and reported a complete remission of the psychotic symptoms. She tolerated quetiapine better than her previous medication. Lorazepam was tapered over the last 2 weeks. Due to persistent sedation, quetiapine dosage was lowered to 800 mg daily. During the following two years, Ms A remained on the same treatment. The severity as well as the number of episodes decreased (2 episodes with psychotic symptoms: 1 manic, 1 depressive over the 2 years) leading to only 1 hospitalisation (21 days) during the observed period. Ms A required, during the reported mood episodes, a temporary increase in quetiapine dosage up to 1400 mg daily, in association with lorazepam up to 10 mg per day. Furthermore, 2 brief hypomanic periods were controlled by an increase of quetiapine dosage, up to 1000 mg daily. In parallel to the reported mood stabilisation, Ms A experienced, for the first time in her adult life, affective stability over the two year period. In addition, her accommodation remained stable during this period. She consulted regularly at our outpatient clinic and received individual psychoeducation sessions aiming at relapse prevention. Quetiapine blood concentration was 110 ng/ml at a dosage of 800 mg/day, indicating good compliance and a quetiapine metabolism in the usual range.[5] Electrocardiogram, serum electrolytes, thyroid hormones, transaminases and blood count were normal. Discussion The present case report describes an important and sustained improvement in mood and psychotic symptoms in a patient with SAD, treated by quetiapine alone, in dosages between 800 to 1400 mg/ day. The improvement observed during the manic and depressive episodes concord with previous studies.[2],[3] Furthermore, quetiapine seems to be well tolerated in dosages higher than 800 mg, as suggested by previous reports.[6] The reduction in the number and severity of episodes, during the two year observation, leads to the consideration of the potential long-term mood stabilising properties of quetiapine. This observation concords with previous studies on the mood stabilising effect of olanzapine, another atypical antipsychotic.[7] We cannot exclude that the observed improvement is the result of natural evolution or of impact of other factors such as psychosocial/personal issues, psychoeducation or interactions of those factors with quetiapine compliance. Conclusion This case suggests that quetiapine has a long-term mood stabilising effect. Double-blind, long-term controlled studies with quetiapine are needed to determine the effectiveness of this agent in the maintenance treatment of bipolar and schizoaffective bipolar disorders.References
Copyright 2006 - Indian Journal of Pharmacology |
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