Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel st, 12-0, 08036, Barcelona, Catalonia, Spain.
Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, 7 Dębinki St., 80-952 Gdańsk, Poland.
Eur Neuropsychopharmacol. 2019 Nov;29(11):1199-1212. doi: 10.1016/j.euroneuro.2019.09.007. Epub 2019 Oct 4.
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.
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.
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.
未经治疗的双相情感障碍（BD）患者在围产期有高达 2/3 的复发率，这对 BD 的临床结局和胎儿及儿童发育有重要影响。丙戊酸（VPA）是 BD 最有效的治疗方法之一，但与暴露于 VPA 的儿童发生严重神经发育障碍的风险最高有关。这导致监管机构和临床指南对其使用进行了更严格的限制。
一组 BD 药物治疗专家对科学文献和临床指南进行了非系统性综述，截至 2019 年 3 月，并为有生育能力的 BD 女性 VPA 转换/停药提供了具体的循证和经验临床建议。
在面对面会议审查证据后，专家组得出结论，需要考虑几个临床标准来做出关于 VPA 停药和转换的临床决策。平台交叉递减转换可能是首选。突然转换可能会增加复发的风险。
正在接受 VPA 治疗的 BD 育龄妇女必须根据临床情况进行个体化管理。怀孕期间必须停止使用 VPA。停药/转换过程的持续时间取决于不同的临床变量。对于计划/非计划妊娠的稳定 BD 患者，锂、拉莫三嗪、喹硫平、奥氮平或阿立哌唑是转换的较好选择。对于计划妊娠的不稳定 BD 患者，稳定是首要的。预防产后发作需要在分娩前或分娩后恢复有效的治疗（在 VPA 的情况下）。VPA 仍然是产后及以后的一个选择。
