Pharmacotherapy for the peripartum management of bipolar disorder

ABSTRACT

Introduction: The peripartum period in bipolar disorder (BD) patients is associated with high risk of relapse. Relapse during this period may affect fetal and child development. The consequences of psychotropic medication during pregnancy are also a major concern. The extent to which mood stabilizers may potentially affect the embryogenesis or the child development varies from high (e.g. valproate) to less clear and more debated (e.g. lithium).

Areas covered: This review describes the current state of evidence with respect to the impact of recommended pharmacological interventions for BD during the peripartum period. It compares recent international treatment guidelines for the management of BD during the peripartum period. Last, this review presents a summary of key recommendations for BD women of childbearing age, for BD women during pregnancy and postpartum period from the international guidelines.

Expert opinion: Management of the pharmacological treatment for BD patients during the perinatal period is challenging. Although treatment guidelines may be of significant help, high heterogeneity exists across them. Shared decision-making represents a useful patient-centered approach during the perinatal period. Large cohort studies are needed to better identify risk associated to treatment discontinuation or treatment exposure.

KEYWORDS:

• Bipolar disorder
• childbearing age
• pregnancy
• breastfeeding
• guidelines
• pharmacotherapy

Article highlights

• Risk of relapse both during pregnancy and postpartum period is high when stopping medication

• Prescription during perinatal period needs one of the most challenging risk-benefit analysis in medicine

• Risk of congenital malformations associated with medication provides guidance in the choice of mood stabilizer in bipolar women of childbearing age (i.e. valproate)

• Risk associated with valproate is today well known, safety guarantees of other anticonvulsants and lithium are uncertain (absence of consensus between international guidelines) during pregnancy

• There is a global consensus of dopamine antagonist/partial agonists to be used during breastfeeding at least at minimum dosage

• Large cohort studies are needed to better identify risk associated to treatment discontinuation or treatment exposure and to long-term effect of fetal exposure

This box summarizes key points contained in the article.

Declaration of interest

L Samalin has received grants, honoraria, and/or consulting fees from Janssen-Cilag, Lundbeck and Otsuka. R Belzeaux has received honoraria and consulting fees from Sanofi. A Murru has received grants, honoraria, and/or consulting fees from Janssen Pharmaceuticals, Lundbeck, and Otsuka. I Pacchiarotti has received CME-related honoraria, and/or consulting fees from Adamed, Janssen-Cilg and Lundbeck. E Vieta has received grants and served as consultant, advisor or CME speaker for the following entities: AB-Biotics, Abbott, Allergan, Angelini, AstraZeneca, Bristol–Myers Squibb, Ferrer, Forest Research Institute, Gedeon Richter, GlaxoSmithKline, Janssen, Lundbeck, Otsuka, Pfizer, Recordati, Roche, Sage, Sanofi, Servier, Shire, Sunovion, Takeda, Telefonica, the Brain and Behaviour Foundation, the Generalitat de Catalunya, the Spanish Ministry of Science, Innovation and Universities (CIBERSAM), the Seventh European Framework Programme, Horizon 2020, and the Stanley Medical Research Institute. Finally, P Llorca has received grants, honoraria, and/or consulting fees from Allergan, Gedeon Richter, Janssen-Cilag, Lundbeck, Otsuka, Recordati, Sanofi and Teva. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Referee disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.