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the_ninth_sin

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Which of the following should be used as a first choice treatment in children and adolescents with acute manic or mixed episodes?

Sodium valproate Lithium

Carbamazepine Lamotrigine

Olanzapine

- isnt answer olanzapine.

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Which of the following should be used as a first choice treatment in children and adolescents with acute manic or mixed episodes?

   Sodium valproate  Lithium

 Carbamazepine   Lamotrigine

Olanzapine

- isnt answer olanzapine.

sodium valproate is the answer

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Which of the following should be used as a first choice treatment in children and adolescents with acute manic or mixed episodes?

   Sodium valproate  Lithium

 Carbamazepine   Lamotrigine

Olanzapine

Nice guidelines, page 275 : valproate is effective in approximately 50% of acute mania or mixed episodes. (effectiveness is a pragmatic trial of every day clinical practice).

For olanzapine, open-label studies support efficacy in acute mania. (efficacy is cluster trial and could not be generalized.)

- isnt answer olanzapine.

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Nice guidelines, page 275 : valproate is effective in approximately 50% of acute mania or mixed episodes. (effectiveness is a pragmatic trial of every day clinical practice).

For olanzapine, open-label studies support efficacy in acute mania. (efficacy is cluster trial and could not be generalized.)

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In children,the only drug liscenced for BAD IN UK is Lithium.

But the NICE guidelines suggests Atypical Antipsychotics, and if no response,add lithium/valproate.(avoid valproate in young/adolescent

girls) NICE CG38.

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I would go with Lithium (same as adults). In clinical practice, we will also add olanzapine in the initial stages as Lithium will take atleas 4-6 wks to show its effect.

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Nice guidelines, page 275 : valproate is effective in approximately 50% of acute mania or mixed episodes. (effectiveness is a pragmatic trial of every day clinical practice).

For olanzapine, open-label studies support efficacy in acute mania. (efficacy is cluster trial and could not be generalized.)

Sorry, it's maudsley guidelines, not nice.

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NICE guidelines is very clear about maintainence medication in children (pg 27, quick reference)

1st line - Antipsychotic

2nd line - Li in females and Li or Valp in males

It is less clear about acute mania...

But certain assumptions can be made...

1. The management is same as adults, except for the doses (lower)

2. If the patient is already on a medication, then 1st step is to adjust the dose, whatever the medication...

3. If the patient is not on any medication, and has responded to some medication in the past, start that....

4. If it is the first episode, then antipsychotic is the first choice...

'Consider, taking into account side effects and future prophylaxis:

an antipsychotic (normally olanzapine, quetiapine or risperidone), especially if symptoms are severe or behaviour disturbed

– valproate if symptoms have responded before (but avoid in women of childbearing potential)

– lithium if symptoms have responded before, and are not severe'

This is from pg 10 - quick reference...

From the above statement, they recommend Li or Val in acute mania only if they have responded before... but they dont say that about antipsychotics...

The other point is, they ask us to consider what medication we may consider using as maintainence... and in children, it is 'an antipsychotic'...

So... taking all points into consideration,  The first choice would be an 'antipsychotic'...

The other point is that Li is probably not the choice in a mixed episode... and from a clinical point of view, we would start an antipsychotic anyway, whether its a child or adult... (in acute mania)

Carbamazepine, Lamotregine are out of question...

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follow the suggestions by NICE-is gold standard in UK

I think NICE trumps Maudsley... because it is based on metaanalysis... although I dont know much about Maudsley guidelines

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In children lithium can be given after age of 12, in above Q, age has not mentioned , so i will go for Olanzapine

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Valproate is the medication of first choice, followed by lithium and then carbamazepine.

It would be great if you could give us a reference SPR (preferably a standard one)

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