Allopurinol

Anti-gout (reduces uric acid by inhibiting xanthine oxidase)

Start 100 mg/day, raise by 100 mg every 3-7 days toward 300-600 mg/day (divided BID).

Augments mood stabilizers in mania with small effect size in 5 RCTs, though may work better when added to lithium than antipsychotics.

Mechanism: Raises adenosine through the purinergic system, which includes the anticonvulsant and antikindling effects.

TOLERABILITY: rare joint pain.

RISKS: Severe allergic rash (similar to lamotrigine, stop if any rash develops).

Mania

Allopurinol use based on multiple controlled trials in bipolar mania (Bartoli F et al, Br J Psychiatry 2017;210(1):10-15).

Allopurinol’s side effects reviewed with patient.