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TOP双極性障害急速交代型双極性感情障害

急速交代型双極性感情障害

通常，急速交代型は12ヵ月間において（軽）躁病エピソードとうつ病エピソードが4回以上ある（または極の明確な交代が4回認められる）双極性障害と定義されている。一般に非急速交代型双極性障害と比較して薬物療法に対する反応が悪いと考えられており1, 2，うつ状態の罹病率と自殺リスクがかなり高い3。急速交代型と非急速交代型の双極性障害患者の間で臨床的にみられる重要な違いは，うつ状態の罹患率が高いこと，不安障害，嗜癖，過食症，境界性パーソナリティ障害の発症率が高いこと，さらにうつ病期の非定型的な特徴や，易刺激性，リスク行動，衝動性，激越等の症状である。急速交代型の患者は非急速交代型の患者と比べて機能が低下しており，肥満が多く，治療に要する薬剤の数が多い4。急速交代型の患者では他の双極性障害患者と比べて，薬剤の用量が若干高い傾向がある5。

表2.8に急速交代型の治療戦略を示す（根拠となるデータは極めて限られており，薬剤の直接比較も非常に少ない）6, 7。この治療戦略は，発表されたシステマティック・レビューの結果とほぼ一致している7, 8。NICEは2016年に，急速交代型では従来型とは異なる管理をしなければならないというエビデンスはないと結論付けた9。正式な第一選択または併用療法はなく，処方は気分エピソードを予防または治療するためにすでに用いられている治療に左右される側面がある。急速交代型では非急速交代型と比較して，リチウムが有効となる可能性が低いことを示唆するエビデンスがあり44，この知見は精神科医の経験によって裏付けられている45。

実際には，治療への反応は個々の患者によって異なり，1つか2つの薬剤にのみ反応する場合もある。急速交代型双極性障害の約1/3は自然にまたは治療によって寛解に至るが46，ほとんどの患者で再燃を繰り返す可能性がある47。

表2.8　急速交代型双極性障害に対して推奨される治療法

ステップ 提案される治療法
ステップ1 すべての患者で抗うつ薬を中止する10-14
（SSRIの継続を支持するエビデンスもあるが，これについては議論もある15, 16）
ステップ2 考えられる要因を評価する
［例：アルコール，甲状腺機能不全（抗甲状腺抗体17等），外的ストレス要因］2
ステップ3 気分安定薬を最適化する18-21（血漿中濃度を測定する），そして
気分安定薬の併用を検討する
（例：リチウム＋バルプロ酸，リチウム＋ラモトリギン，バルプロ酸＋カルバマゼピン）またはステップ4へ
ステップ4 他の選択肢（通常は補助療法）を検討する（以下にアルファベット順で示す。望ましい選択肢を太字で示している）
アリピプラゾール22, 23（15-30mg/日）
クロザピン24（通常の投与量）
ラモトリギン25-27（225mg/日まで）
レベチラセタム28（2,000mg/日まで）
nimodipine29, 30（180mg/日）
オランザピン18（通常の投与量）
クエチアピン31-34（300-600mg/日）
リスペリドン35-37（6mg/日まで）
チロキシン38-40（150-400μg/日）
トピラマート41（300mg/日まで）
薬剤は患者側の要因に基づいて選択する。現時点では，薬剤の選択に役立つような有効性を比較したデータはほとんどない。クエチアピンを支持するデータ31-33がおそらく最善であるが，アリピプラゾールまたはオランザピンに対する優越性のエビデンスはない。レベチラセタム，nimodipine，チロキシン，トピラマートを支持するデータは限られている。
クロザピンは，治療抵抗性双極性障害（定義に急速交代型が含まれると考えられる）において急性期および長期の有効性を示し24, 43，明確な役割をもつ42。

（仁王　進太郎）

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