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Meduri M, Gregoraci G, Baglivo V, Balestrieri M, Isola M, Brambilla P. A meta-analysis of efficacy and safety of aripiprazole in adult and pediatric bipolar disorder in randomized controlled trials and observational studies. J Affect Disord 2016; 191:187-208. [PMID: 26674213 DOI: 10.1016/j.jad.2015.11.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/27/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Aripiprazole (ARP) has been shown to be effective in the treatment of bipolar disorder (BD). However, no prior investigation considered both randomized clinical trials (RCTs) and non-RCTs. We here evaluated the efficacy and safety of ARP compared with placebo (PCB) and other drugs at 3- and 12-weeks in adult and pediatric population including, for the first time, both observational and controlled studies. METHODS All studies were systematically located by searching electronic sources (EMBASE, MEDLINE, CINHAIL, PsychINFO, Cochrane Central Register of Controlled Trials, Scopus and ClinicalTrials.gov) till June 30th, 2015. The primary outcome was ARP efficacy (mean change from baseline in Young Mania Rating Scale); secondary outcomes regarded acceptability and safety. Results Sixteen RCTs and 6 non-RCTs met our inclusion criteria; 2505 and 2932 patients were included in the analyses of acute and stabilization phase, respectively. In both the acute and stabilization phases ARP efficacy was superior to PCB and comparable to other drugs. The safety profile was similar to other drugs considering in particular sedation, akathisia, weight gain, extrapyramidal and gastroenteric symptoms, with a significant lower risk of hyperprolactinemia particularly at 12-weeks. LIMITATIONS Data on failed trials are generally limited. CONCLUSIONS ARP resulted to be an effective treatment in children and adults with BD at 3- and 12-weeks both in a controlled experimental setting or in the real world clinical practice, being poorly associated with hyperprolactinemia. Larger studies are needed to confirm our results related to the maintenance phases and to the pediatric bipolar population.
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Affiliation(s)
- Martina Meduri
- Department of Experimental and Clinical Medical Sciences, ICBN, University of Udine, Udine, Italy
| | - Giorgia Gregoraci
- Department of Biological and Medical Sciences, University of Udine, Udine, Italy
| | - Valentina Baglivo
- Department of Experimental and Clinical Medical Sciences, ICBN, University of Udine, Udine, Italy
| | - Matteo Balestrieri
- Department of Experimental and Clinical Medical Sciences, ICBN, University of Udine, Udine, Italy
| | - Miriam Isola
- Department of Biological and Medical Sciences, University of Udine, Udine, Italy
| | - Paolo Brambilla
- Department of Neurosciences and Mental Health, Psychiatric Clinic, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Psychiatry and Behavioural Sciences, University of Texas Health Science Center at Houston, TX, USA.
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Easing the burden of bipolar disorder: from urgent situations to remission. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:391-402. [PMID: 19158978 DOI: 10.4088/pcc.v10n0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cheniaux E. [The pharmacological treatment of bipolar disorder: a systematic and critical review of the methodological aspects of modern clinical trials]. BRAZILIAN JOURNAL OF PSYCHIATRY 2011; 33:72-80. [PMID: 21537724 DOI: 10.1590/s1516-44462011000100015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 07/07/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review systematically the main clinical trials on the pharmacological treatment of bipolar disorder and to make a critical analysis of their methodological aspects. METHOD A search in Medline, ISI and PsycINFO databases was conducted, using the following search terms: "bipolar", "randomized", "placebo" e "controlled". Randomized, double-blind, placebo-controlled clinical trials on the pharmacological treatment of bipolar disorder were selected. Besides, according to our criteria, samples had to consist of at least 100 patients and experimental drug had to be used as monotherapy. RESULTS 34 articles met our selection criteria. All drugs currently indicated for mania, bipolar depression and maintenance treatment of bipolar disorder were more effective than placebo in at least one clinical trial. However, these studies had highly selected samples, high dropout rates and low response rates. CONCLUSION Modern clinical trials on pharmacological treatment of bipolar disorder have important methodological limitations. So, their results should be taken with caution.
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Affiliation(s)
- Elie Cheniaux
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
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Fountoulakis KN, Vieta E, Schmidt F. Aripiprazole monotherapy in the treatment of bipolar disorder: a meta-analysis. J Affect Disord 2011; 133:361-70. [PMID: 21040979 DOI: 10.1016/j.jad.2010.10.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 09/29/2010] [Accepted: 10/10/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Aripiprazole is approved for the acute and maintenance treatment of manic and mixed episodes associated with bipolar I disorder. The aim of the present work was to review and meta-analyze the findings of all the available randomized double-blind controlled trials (RCTs) on the efficacy of aripiprazole in the treatment of bipolar disorder. MATERIAL AND METHODS Aripiprazole RCTs were identified with a systematic search of MEDLINE and repositories. Standard meta-analytic techniques were applied. RESULTS Two thousand three hundred and three patients took part in the aripiprazole acute mania RCTs. At week 3 the pooled aripiprazole vs. placebo effect size was 0.34 and the NNT was 6 for response and 14 for remission. On average, response started at day 3. Suicide rates were negligible for all groups in mania but they were not reported in the acute depression trials. The meta-analysis of acute bipolar depression RCTs revealed a significant difference at week 8 with a weak effect size equal to 0.17. The analysis of maintenance data suggest that the median survival time for the aripiprazole group was not evaluable (very long), while the median survival time for placebo was 118-203 days depending on the clinical subpopulation. DISCUSSION The current meta-analysis supports the usefulness of aripiprazole during all phases of bipolar illness. Its effect against acute bipolar depression is weak and the efficacy during the maintenance phase is proven only against new manic episodes in patients with an index manic episode who had previously responded to aripiprazole during the acute phase.
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Tsai AC, Rosenlicht NZ, Jureidini JN, Parry PI, Spielmans GI, Healy D. Aripiprazole in the maintenance treatment of bipolar disorder: a critical review of the evidence and its dissemination into the scientific literature. PLoS Med 2011; 8:e1000434. [PMID: 21559324 PMCID: PMC3086871 DOI: 10.1371/journal.pmed.1000434] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 03/23/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Aripiprazole, a second-generation antipsychotic medication, has been increasingly used in the maintenance treatment of bipolar disorder and received approval from the U.S. Food and Drug Administration for this indication in 2005. Given its widespread use, we sought to critically review the evidence supporting the use of aripiprazole in the maintenance treatment of bipolar disorder and examine how that evidence has been disseminated in the scientific literature. METHODS AND FINDINGS We systematically searched multiple databases to identify double-blind, randomized controlled trials of aripiprazole for the maintenance treatment of bipolar disorder while excluding other types of studies, such as open-label, acute, and adjunctive studies. We then used a citation search to identify articles that cited these trials and rated the quality of their citations. Our evidence search protocol identified only two publications, both describing the results of a single trial conducted by Keck et al., which met criteria for inclusion in this review. We describe four issues that limit the interpretation of that trial as supporting the use of aripiprazole for bipolar maintenance: (1) insufficient duration to demonstrate maintenance efficacy; (2) limited generalizability due to its enriched sample; (3) possible conflation of iatrogenic adverse effects of abrupt medication discontinuation with beneficial effects of treatment; and (4) a low overall completion rate. Our citation search protocol yielded 80 publications that cited the Keck et al. trial in discussing the use of aripiprazole for bipolar maintenance. Of these, only 24 (30%) mentioned adverse events reported and four (5%) mentioned study limitations. CONCLUSIONS A single trial by Keck et al. represents the entirety of the literature on the use of aripiprazole for the maintenance treatment of bipolar disorder. Although careful review identifies four critical limitations to the trial's interpretation and overall utility, the trial has been uncritically cited in the subsequent scientific literature. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Alexander C. Tsai
- Robert Wood Johnson Health and Society Scholars Program, Harvard
University, Cambridge, Massachusetts, United States of America
| | - Nicholas Z. Rosenlicht
- Department of Psychiatry, University of California at San Francisco and
San Francisco Veterans Affairs Medical Center, San Francisco, California, United
States of America
| | - Jon N. Jureidini
- Discipline of Psychiatry, University of Adelaide, Adelaide, South
Australia, Australia
| | - Peter I. Parry
- Child and Adolescent Mental Health Service, Division of Mental Health,
Flinders University, Adelaide, South Australia, Australia
| | - Glen I. Spielmans
- Department of Psychology, Metropolitan State University, St. Paul,
Minnesota, United States of America
| | - David Healy
- Department of Psychological Medicine, Cardiff University, Cardiff, Wales,
United Kingdom
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De Fazio P, Girardi P, Maina G, Mauri MC, Mauri M, Monteleone P, Perini GI, Perugi G, Rossi A. Aripiprazole in Acute Mania and Long-Term Treatment of Bipolar Disorder. Clin Drug Investig 2010; 30:827-841. [DOI: 10.2165/11584270-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Woodward TC, Tafesse E, Quon P, Lazarus A. Cost effectiveness of adjunctive quetiapine fumarate extended-release tablets with mood stabilizers in the maintenance treatment of bipolar I disorder. PHARMACOECONOMICS 2010; 28:751-764. [PMID: 20623994 DOI: 10.2165/11538350-000000000-00000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Bipolar I disorder (BPD I) is a recurrent illness that affects 1% of the US population and constitutes a large economic burden. However, few studies have investigated the cost effectiveness of maintenance treatment options for BPD I. OBJECTIVE To determine the cost effectiveness of maintenance treatment with quetiapine fumarate extended-release (XR) tablets in combination with mood stabilizers (lithium or divalproex) in comparison with the following treatments: placebo in combination with lithium or divalproex; no maintenance treatment; lithium monotherapy; lamotrigine monotherapy; olanzapine monotherapy; and aripiprazole monotherapy. METHODS The analysis was conducted from the societal and payer perspectives in the US, using a Markov model. The model simulated a cohort of 1000 stabilized BPD I patients and estimated the quarterly risk in three health states: euthymia, mania and depression. Efficacy data were derived from two randomized, double-blind trials comparing quetiapine + lithium/divalproex with placebo + lithium/divalproex for up to 2 years, as well as other published literature. Resource data were extracted from published literature. Drug costs, hospitalizations and physician visits were among the direct costs. Indirect costs included absenteeism, and mortality rates included suicide. Benefits and costs were discounted at 3% and the price reference year was 2009. Endpoints included number of acute mood episodes, hospitalizations due to an acute mood event and costs per QALY. Probabilistic sensitivity analysis (PSA) was conducted to evaluate uncertainty in the model inputs. RESULTS Treatment with quetiapine XR + lithium/divalproex was associated with reductions in acute mania (46%), acute depression (41%) and related hospitalizations (44%) compared with placebo + lithium/divalproex, and similar reductions in events were observed relative to lithium monotherapy. In the base-case analysis from the payer perspective, the discounted incremental cost per QALY for quetiapine XR + lithium/divalproex compared with placebo + lithium/divalproex was $US22 959, and compared with lithium monotherapy was $US100 235, while all other comparators were dominated. PSA showed these results to be robust to select assumptions. CONCLUSIONS Quetiapine XR + lithium/divalproex may be a cost-effective maintenance treatment option for patients with BPD I.
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Fountoulakis KN, Gonda X, Vieta E, Schmidt F. Treatment of psychotic symptoms in bipolar disorder with aripiprazole monotherapy: a meta-analysis. Ann Gen Psychiatry 2009; 8:27. [PMID: 20043829 PMCID: PMC2812439 DOI: 10.1186/1744-859x-8-27] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 12/31/2009] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND We present a systematic review and meta-analysis of the available clinical trials concerning the usefulness of aripiprazole in the treatment of the psychotic symptoms in bipolar disorder. METHODS A systematic MEDLINE and repository search concerning clinical trials for aripiprazole in bipolar disorder was conducted. RESULTS The meta-analysis of four randomised controlled trials (RCTs) on acute mania suggests that the effect size of aripiprazole versus placebo was equal to 0.14 but a more reliable and accurate estimation is 0.18 for the total Positive and Negative Syndrome Scale (PANSS) score. The effect was higher for the PANSS-positive subscale (0.28), PANSS-hostility subscale (0.24) and PANSS-cognitive subscale (0.20), and lower for the PANSS-negative subscale (0.12). No data on the depressive phase of bipolar illness exist, while there are some data in favour of aripiprazole concerning the maintenance phase, where at week 26 all except the total PANSS score showed a significant superiority of aripiprazole over placebo (d = 0.28 for positive, d = 0.38 for the cognitive and d = 0.71 for the hostility subscales) and at week 100 the results were similar (d = 0.42, 0.63 and 0.48, respectively). CONCLUSION The data analysed for the current study support the usefulness of aripiprazole against psychotic symptoms during the acute manic and maintenance phases of bipolar illness.
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Fountoulakis KN, Vieta E. Efficacy and safety of aripiprazole in the treatment of bipolar disorder: a systematic review. Ann Gen Psychiatry 2009; 8:16. [PMID: 19635147 PMCID: PMC2724509 DOI: 10.1186/1744-859x-8-16] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Accepted: 07/27/2009] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The current article is a systematic review concerning the efficacy and safety of aripiprazole in the treatment of bipolar disorder. METHODS A systematic Medline and repositories search concerning the usefulness of aripiprazole in bipolar disorder was performed, with the combination of the words 'aripiprazole' and 'bipolar'. RESULTS The search returned 184 articles and was last updated on 15 April 2009. An additional search included repositories of clinical trials and previous systematic reviews specifically in order to trace unpublished trials. There were seven placebo-controlled randomised controlled trials (RCTs), six with comparator studies and one with add-on studies. They assessed the usefulness of aripiprazole in acute mania, acute bipolar depression and during the maintenance phase in comparison to placebo, lithium or haloperidol. CONCLUSION Aripiprazole appears effective for the treatment and prophylaxis against mania. The data on bipolar depression are so far negative, however there is a need for further study at lower dosages. The most frequent adverse effects are extrapyramidal signs and symptoms, especially akathisia, without any significant weight gain, hyperprolactinaemia or laboratory test changes.
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Affiliation(s)
- Konstantinos N Fountoulakis
- Third Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Woodward TC, Tafesse E, Quon P, Kim J, Lazarus A. Cost-effectiveness of quetiapine with lithium or divalproex for maintenance treatment of bipolar I disorder. J Med Econ 2009; 12:259-68. [PMID: 19769548 DOI: 10.3111/13696990903266612] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bipolar I disorder is a recurrent illness that affects 1% of the US population and constitutes a large economic burden. Few studies have investigated the cost-effectiveness of maintenance treatment options. The objective of this analysis was to assess the cost-effectiveness of quetiapine (QTP) in combination with lithium (Li) or divalproex (DVP) compared with that of Li or DVP alone for maintenance treatment of bipolar disorder. METHODS The cost-effectiveness of maintenance treatment with QTP in combination with Li or DVP was compared with placebo (PBO) in combination with Li or DVP from a US direct costs perspective using a Markov model. The model simulated a cohort of 1,000 stabilized patients with bipolar I disorder and estimated the quarterly risk in three health states: euthymia, mania, and depression. Efficacy data were derived from two randomized, double-blind, placebo-controlled trials comparing QTP + Li/DVP with PBO + Li/DVP for up to 2 years. Resource data were obtained from published literature. Direct costs included drug costs, hospitalizations, and physician visits. Outcomes and costs were discounted at 3% and the price reference year was 2007. Endpoints included the number of acute mood episodes, hospitalizations due to an acute mood event, and costs per quality-adjusted life-years. A probabilistic sensitivity analysis (PSA) was conducted to evaluate uncertainty. RESULTS In the base-case analysis, QTP + Li/DVP dominated PBO + Li/DVP. The PSA showed these results to be robust. In addition, treatment with QTP + Li/DVP was associated with reductions in acute manic episodes (46%), acute depressive episodes (41%), and related hospitalizations (44%) compared with PBO + Li/DVP. CONCLUSIONS These analyses, based on two randomized clinical trials, suggest that QTP + Li/DVP is a cost-effective maintenance treatment option for patients with bipolar I disorder compared with Li or DVP alone.
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