Safety and Tolerability of Mood Stabilisers

Safety and tolerability of mood stabilisers are major clinical concerns when used in bipolar patients. Side effects of lithium and some antiepileptics have been reviewed in the context of a spontaneous reporting database over the last 10 years (FDA database and published reports). During pregnancy, antiepileptics show great concerns, and adverse events are all related to childbirth, whilst congenital abnormalities are not higher than previously estimated. Cutaneous adverse reactions are the most prevalent in children and adolescent. In adult lithium-treated patients, nephrotoxicity is still a major problem; the combination with carbamazepine and valproate can increase the risk of hypothyroidism. Hyperparathormonemia and hypercalcaemia are unrecognised and underappreciated adverse effects. Acute exacerbation of psoriasis is still a major problem, and the risk of skin reactions with eosinophilia and systemic symptoms is higher when mood stabilisers are used concomitantly; when associated with antipsychotics, the risk of pneumonia is possible (highest risk for olanzapine plus carbamazepine). A decrease in total body water and the decline of glomerular fi ltration rate represent the main lithium adverse effects in elderly patients. Long-term treatment is associated with impairment in immediate verbal learning and memory and creativity performance. Antiepileptics display signifi cant adverse events (hyponatraemia, cardiac toxicity) and the risk of multiple drug-drug interactions is very high. Cumulative exposure to antipsychotics and mood stabilisers can be associated with vascular stiffness (elevated systolic blood pressure), hypertriglyceridaemia, insulin resistance and low HDL cholesterol. In light of the above considerations, clinicians should continuously and further assess risks and benefi ts of mood stabilisers when treating bipolar patients.