Generic lorazadone has made it more accessible and affordable for managing bipolar symptoms.
Lorazadone's mechanisms involve serotonin antagonism, which increases BDNF and normalizes circadian rhythms.
Deep dives
The Three Ls: Lithium, Lomotrigine, and Lorazadone
Dr. Robert Post, former chief of the National Institute of Mental Health, highlighted the three main medications he relies on for treating bipolar disorder: lithium, lomotrigine, and lorazadone. These three medications have shown effectiveness individually and in combination for managing bipolar symptoms. The recent availability of generic lorazadone has made it more accessible and affordable. Other generic antipsychotics commonly used for bipolar depression, such as quetiapine and the aripiprazole-lamotrigine combination, often come with sedation and metabolic side effects. The only FDA-approved antipsychotics for bipolar depression are a lansopine-fluoxetine combination, quetiapine, lorazadone, cariprazine, and lumateperone.
Different Mechanisms of Antipsychotic Action
Antipsychotics block dopamine, which is responsible for motivation and pleasure. However, their mechanisms of action for treating depression are not fully understood. Each antipsychotic, including lorazadone, has a unique additional mechanism that contributes to its effectiveness against depression. While antipsychotics face challenges in treating depression due to blocking dopamine, they offer benefits beyond neurotransmitter effects. For instance, lorazadone's mechanisms may involve serotonin antagonism, which increases brain-derived neurotrophic factor (BDNF) and normalizes circadian rhythms. This normalization of gene expression related to circadian rhythms is exclusive to lorazadone and lithium.
Dosing and Considerations for Lorazadone
Lorazadone has a favorable dosing range for bipolar depression, with most patients responding well to a middle dose of 40 to 60 mg per day. Its antidepressant effects may intensify as the dosage increases, making it unique among antipsychotics. However, it is important to note that increasing the dose may also lead to akathisia, a common side effect associated with all antipsychotics. Additionally, food and drug interactions affect lorazadone's absorption and metabolism. Taking lorazadone with a meal of at least 350 calories ensures proper absorption, while specific medications and substances can induce or inhibit its metabolism. Lorazadone may offer benefits in cognition, as studies have shown its possible cognitive improvements in people with bipolar depression. Overall, lorazadone is often the first-line choice for bipolar depression due to its low risk of metabolic side effects.
Lurasidone (Latuda) has gone generic. Find out where this antipsychotic fits in bipolar disorder with updates from the 2023 International Bipolar Conference.
Chris Aiken, MD, and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
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