Comparative efficacy of lithium carbonate loading dose versus standard dosing, each combined with quetiapine, in acute mania of bipolar I disorder: a randomized single-blind controlled trial.

introductionBipolar disorder type I is defined by the occurrence of at least one manic episode, presenting with elevated mood, hyperactivity, and restlessness. Effective management relies primarily on pharmacotherapy, with lithium carbonate and quetiapine proven beneficial as monotherapies. Given the chronic nature of the illness and alternating manic–depressive phases, acute mania requires rapid symptom control to prevent functional decline and harm. Although lithium is a cornerstone mood stabilizer, its clinical effect may take days to emerge. Quetiapine, an atypical antipsychotic, provides faster relief in acute mania. Evidence suggests that combining these agents may offer superior control of manic symptoms compared to either drug alone.

objectiveThis study aims to compare the efficacy of a lithium carbonate loading dose combined with quetiapine against the standard lithium carbonate dosage alongside quetiapine for managing acute mania.

methodsThis interventional randomized clinical trial (IRCT20181204041847N2) was a prospectively designed, retrospectively registered study conducted at a psychiatric hospital and conducted on 60 adult inpatients diagnosed with Bipolar I disorder in the acute manic phase, according to DSM-5 criteria and a Young Mania Rating Scale (YMRS) score of ≥ 20. Participants were equally allocated to two arms using block randomization. The loading-dose lithium group received a loading dose of lithium carbonate on Day 1 at 20 mg/kg (maximum 1,800 mg), followed by standard dosing from Day 2 onward. The standard-dose lithium group received lithium carbonate starting at 300 mg/day, increased in 300 mg increments every 2–3 days until reaching 900–1,200 mg/day, with serum concentrations consistently maintained within 0.6–1.2 mEq/L. Quetiapine was initiated at 100 mg/day in two divided doses and titrated by 100–200 mg/day increments to a target of 400–800 mg/day based on clinical response and tolerability. Mania severity was assessed using the YMRS at baseline and on Days 3, 7, and 14 after treatment initiation.

resultsIn this study of 60 patients with acute mania, both treatment groups showed significant reductions in YMRS scores over 14 days (p < 0.001). The loading dose group achieved a greater mean decrease from baseline (− 17.70 ± 3.76) compared with the standard dose group (− 13.96 ± 2.94; p < 0.001). Lithium serum levels reached therapeutic ranges sooner in the loading group (Day 5: 0.82 ± 0.11 mEq/L vs. 0.65 ± 0.13; Day 10: 0.78 ± 0.09 vs. 0.68 ± 0.10). Aggressive/disruptive behavior scores were also lower in the loading group by Day 14 (0.36 ± 0.06 vs. 0.89 ± 0.53; p = 0.012). The incidence of common adverse events was comparable, and no cases exceeded lithium serum levels of 1.4 mEq/L.

conclusionThe study found that adding a lithium loading dose to quetiapine significantly enhanced the reduction of acute mania symptoms compared with standard dosing, without increasing short-term adverse events. These results support the regimen’s clinical benefit, though confirmation through larger, long-term trials is needed. CLINICAL TRIAL NUMBER: IRCT20181204041847N2; Registration Date: 16 August 2023; No: 68,388.