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A single blind case series of tamoxifen in seven patients with bipolar disorder (Bebchuk et al., 2000) was followed by small RCTs which show significant improvement over placebo in 13 women with mania (Kulkarni et al., 2006), 16 patients with mania/mixed states (Zarate et al., 2007) and 21 adults with manic/mixed states (Yildiz et al., 2008)

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The more clinically important question is how often this produces meaningful perioperative harm, which patients are at highest risk, and how clinicians should balance aspiration prevention against the metabolic, cardiovascular, logistical, and equity-related consequences of withholding therapy

This is an advanced strategy that requires already having a solid baseline protocol established, but it demonstrates the flexibility that understanding pharmacokinetics provides

At the same time, they suppress glucagon, a hormone that tells the liver to release stored sugar