Abstract
BackgroundType-1 diabetes mellitus (DM) is a lifelong serious condition which often renders the application of standard treatment options for patients' comorbid conditions, such as bipolar disorder I, risky – especially for acute manic episodes. We present such a case whereby the application of standard anti-manic treatments would have jeopardized a patient whose physical condition was already compromised by DM.MethodsWe report the case of a 55-year-old female with a history of type-1 DM since the age of 11, and severe ocular and renal vascular complications thereof. While on the waiting list for pancreatic islet cell transplantation, she developed a manic episode that proved recalcitrant to a treatment with gabapentin, lorazepam and quetiapine. Moreover, her mental state affected adversely her already compromised glycemic control, requiring her psychiatric hospitalization. Her psychotropic medication was almost discontinued and replaced by oxcarbazepine (OXC) up to 1800 mg/day for 10 days.ResultsThe patient's mental state improved steadily and on discharge, 3 weeks later, she showed an impressive improvement rate of over 70% on the YMRS. Moreover, she remains normothymic 6 months after discharge, with OXC at 1200 mg/day.ConclusionStandard prescribing guidelines for acute mania recommend a combination of an antipsychotic with lithium or, alternatively, a combination of an antipsychotic with valproate or carbamazepine. However, in our case, administration of lithium was at least relatively contra-indicated because of patient's already compromised renal function. Furthermore, antipsychotics increase glucose levels and thus were also relatively contra-indicated. Moreover, the imminent post-transpantation immunosupressant treatment with immuno-modulating medicines also contra-indicated both valproate and carbamazepine. Despite the severe methodological limitations of case reports in general, the present one suggests that OXC as monotherapy might be both safe and efficacious in the treatment of acute mania in patients with early-onset type-1 DM, whose already compromised physical condition constitutes an absolute or relative contra-indication for the administration of standard treatments, though there are no, as yet, randomized clinical trials attesting to its efficacy unambiguously.
Highlights
Type-1 diabetes mellitus (DM) is a lifelong serious condition which often renders the application of standard treatment options for patients' comorbid conditions, such as bipolar disorder I, risky – especially for acute manic episodes
Nowadays an abundance of literature is available attesting to both the strong relationship between bipolar disorder (BPD) and type-2 DM [1,2] and the definite or likely increased risk for the emergence of a metabolic syndrome, including type-2 DM, in newly-diagnosed patients with BPD treated with antipsychotics, especially atypical ones [3]
Regular laboratory investigations did not reveal any hyponatremia, a rare though severe possible side effect of OXC. According to both the American Psychiatric Association [8] and the Maudsley prescribing guidelines [9], the standard treatment of acute mania for patients with BPD consists of a combination of an antipsychotic with lithium salts or alternatively in a combination of an antipsychotic with valproate or carbamazepine, possibly with a benzodiazepine as an adjunctive medication
Summary
Type-1 diabetes mellitus (DM) is a lifelong serious condition which often renders the application of standard treatment options for patients' comorbid conditions, such as bipolar disorder I, risky – especially for acute manic episodes. We present such a case whereby the application of standard anti-manic treatments would have jeopardized a patient whose physical condition was already compromised by DM. Treatment options of patients' comorbid conditions are often restricted, as their side effects frequently threaten the already compromised physical condition of the patients. To the best of our knowledge there are no available studies or reports on safe and efficacious treatment modalities for newly-diagnosed acute mania in patients suffering from type-1 DM. In the present paper we report on such a case, treated safely and effectively with oxcarbazepine (OXC) as monotherapy
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