From the Clinical Practice Guidelines for the Management of Borderline Personality Disorder, Australian Government National Health and Medical Research Council., 2013www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh25_borderline_personality_guideline.pdfEffects of pharmacotherapy on specific outcomes
Placebo-controlled clinical trials of the following medicines were available for meta-analysis
(Table 5.3 and Section 5.2):
• antidepressant agents including fluvoxaminen (a selective serotonin reuptake inhibitor) and phenelzine (a monoamine oxidase inhibitor)
• anticonvulsant agentso including carbamazepine, valproate,p lamotrigine and topiramate
• antipsychotic agentsq including haloperidol, a first-generation (‘conventional’ or ‘typical’) antipsychotic agent, and the second-generation (‘atypical’) antipsychotic agents aripiprazole, olanzapine and ziprasidone. No studies were identified that evaluated the use of quetiapine in people with BPD.
The findings of the meta-analyses should be interpreted with caution due to the small number of trials for most individual agents and pharmacological classes, and inconsistency between trials for some outcome measures (details in Appendix H). Wide confidence intervals for some studies suggest relatively high variance within those study samples. Included clinical trials do not capture long-term effects of treatment.
Individual agents showed mixed effects on various outcomes compared with placebo, but none showed a consistent, clinically significant benefit across most relevant target outcomes. Overall, aripiprazole achieved the most consistent benefits across several outcome measures, but other agents may be useful in the management of specific symptoms.Findings of the meta-analyses for specific medicines included the following (versus placebo):
• Among the antidepressant medicines
–– fluvoxamine (one trial49) was associated with an improvement in BPD symptoms,
but not in anger
–– phenelzine was associated with an improvement in hostility (two trials53, 209), but not in BPD symptoms (two trials53, 209), general psychopathology (two trials53, 209), depression(two trials53, 209), anxiety (one trial53), or general functioning (two trials 53, 209).
• Among the anticonvulsant medicines
–– carbamazepine (one trial41) was not associated with significant improvements in any of the outcomes included (general psychopathology, hostility, anxiety, depression, general functioning, and interpersonal and social functioning)
–– valproater was associated with significant improvements in irritability (one trial43), depression (two trials42, 43) and in interpersonal and social functioning (one trial42), but not in anger (two trials42, 43), hostility (one trial42), or suicidality (one trial43)
–– lamotrigine was associated with a significant improvement in anger (one trial48) but not BPD symptoms (one trial207)
–– topiramate was associated with a significant improvement in general psychopathology (one trial45), hostility (one trial45), anxiety (one trial45) and in interpersonal and social functioning (one trial45), but not in anger (two trials46, 47) or depression (one trial45).
• Among the antipsychotic medicines
–– haloperidol was associated with a significant improvement in general functioning two trials53, 208), but a significant worsening of depression (two trials53, 208), and no change in BPD symptoms (two trials53, 208), general psychopathology (two trials53, 208), hostility (two trials53, 208) or anxiety (one trial53)
–– aripiprazole (one trial59) was associated with significant improvements in general psychopathology, anger, hostility, depression, anxiety, and in interpersonal and social functioning
–– olanzapine was associated with improvements in BPD symptoms (two trials55, 57), general psychopathology (two trials55, 57), hostility (one trial57) and irritability (one trial57), and general functioning (two trials55, 57), but not anger (three trials54, 55, 57), depression (one trial54), anxiety (one trial54), suicidality (two trials55, 57) or interpersonal and social functioning (two trials54, 55). Based on pooled data from four trials,54-57 olanzapine was not associated with significantly more weight gain than placebo.
–– ziprasidone (one trial60) was not associated with significant improvements in any of the included outcomes (BPD symptoms, general psychopathology, anger, hostility, depression, anxiety, or suicidality).
The Committee determined that reliable evidence-based recommendations could not be made about the use of a particular agent to target specific outcomes where fewer than three randomized placebo-controlled clinical trials were available for meta-analysis.General considerations for the use of pharmacotherapy in BPD
Any pharmacological treatment for a person with BPD should be part of a documented management plan and should be reviewed regularly for therapeutic and adverse effects. When selecting medicines, the prescriber and person with BPD should discuss and agree on specific goals of treatment. Before prescribing any medicine for a person with BPD, prescribers should carefully consider potential interactions with alcohol and other substances, potential drug-to-drug interactions with other prescription and non-prescription medicines, and potential adverse effects in
overdose. People with BPD are at elevated risk of attempted suicide using prescription
medicines210 (e.g. monoamine oxidase inhibitors, tricyclic antidepressant agents, lithium).
Use one medicine at a time and avoid polypharmacy. Review its efficacy and discontinue before trialling another medicine.
If medicines are prescribed to manage acute crisis, the management plan should specify dose and duration of treatment. The length of crises may vary.
Health professionals should explain to people with BPD that medicines only have a limited role in the management of BPD and may have unwanted effects.
BPD is not listed as an approved indication for any medicine licensed in Australia by the Therapeutic Goods Administration, nor is any medicine reimbursed by the Pharmaceutical Benefits Scheme specifically for the treatment of BPD.