2.16: Bipolar Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

When is acute hypomania seen?

A

Bipolar II

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

4 Stages of Bipolar disorder that need to be treated? Which type are they seen in?

A
  1. Acute Mania: I
  2. Acute Hypomania: II
  3. Bipolar depression: I and II
  4. Bipolar maintenance: I and II
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Consensus on how bipolar depression should NOT be treated?

A
  • Should NOT be treated ONLY with an antidepressant
  • Fear is it will bring them out of depression and flit into manic episode
  • Mood stabilized should be given with antidepressant
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

First line treatment in bipolar disorder?

A

Lithium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Onset of lithium?

A

2 - 3 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What does “better from above than from below” mean?

A
  • Better at treating mania than depression

- This is case with lithium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Which stages does lithium treat?

A
  1. Bipolar depression
  2. Bipolar mania: better at mania
  3. Maintenance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What does lithium reduce the risk of?

A
  • Suicide

- Effective in BP I, II, and MDD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What drug reduces the risk of suicide in patients?

A
  1. Lithium

2. Clozaril

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is 5ht?

A

Serotonin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Effect of lithium on NTs?

A
  1. Increased effects of 5-ht
  2. Decreased turnover of NE and DA
  3. Increased synthesis of Ach
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Excretion and metabolism of Li?

A
  • 100% renal excretion

- 0 hepatic metabolism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Therapeutic windows of lithium?

A

Acute mania: .6 - 1.2 meq/L

Maintenance: .6 - .7 meq/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Absorption and binding of Li?

A
  • Well absorbed in GI tract: peak levels in .5 - 2 hrs

- NO protein binding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Li effects on bipolar disorder?

A
  1. Reduces suicide risk

2. Enhances antidepressant effects in MDD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Blood monitoring of Li?

A
  • 20 Hr. halflife

- Blood draw 5 - 7 days after first / new dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Through draw of Li?

A
  • 12 hours after last dose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How does kidney handle Li?

A
  1. Freely filtered in glomerulus
  2. Reabsorbed with Na in proximal tubule
  3. Resorbed by principal epithelial cells in Na channel of collecting duct
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Drugs involved in urinary alkalization?

A

“Carbonic anhydrase inhibitors”

  1. Acetazolamide
  2. Dichlorphenamide
  3. Methazolamide
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What does carbonic anhydrase do?

A
  • Catalyzes conversion of H2O and CO2 into bicarb and H
  • Found in tubule epithelium
  • Release H into lumen to combine with bicarb
  • Without this H, Bicarb has nothing to combine with and urine is alkalized
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Impact of carbonic anhydrase inhibitors on Li?

A
  • Decrease blood [Li]
  • Block Bicarb reabsorption in proximal tubule
  • Li and Na follow to distal tubule
  • Some is reabsorbed, but net loss in urine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the osmotic diuretics?

A
  1. Mannitol
  2. Urea
    * **Work at proximal tubule
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Impact of osmotic diuretics on Li?

A
  • Decrease blood [Li]
  • Increase tubule osmolality
  • Increased water and Electrolyte (Na/Li) excrtion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Impact of loop diuretics on Li?

A
  • Little to no change

- Furosemide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Impact of thiazide diuretics on Li?

A

Increase [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Trend of diuretic impact on Li?

A
  • Drugs acting closer to glomerulus, decrease [Li]

- Drugs acting further from glomerulus, increases [Li]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Impact of K sparing diuretics on Li?

A
  • Increased [Li] in blood
  • Spironolactone and Amiloride
  • ***Amiloride thought to be protective against NDI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What are the K sparing diuretics?

A
  1. Spironolactone

2. Amiloride

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Impact of ACEIs and ARBs on Li?

A

Increased [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Impact of dehydration on Li?

A

Increased [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Impact of pregnancy on Li?

A

Decreased [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Impact of Na depletion on Li?

A

Increased [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Impact of renal impairment on Li?

A

Increased [Li] in blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Impact of age on Li?

A

Increased [Li] in blood

35
Q

Impact of NSAIDs on Li?

A

Increased [Li] in blood

36
Q

Impact of COXII inhibitors on Li?

A

Increased [Li] in blood

37
Q

Impact of caffeine on Li?

A

Decreased [Li] in blood

38
Q

Impact of phyllines on Li?

A

Decreased [Li] in blood

39
Q

Common side effects of Li?

A
  1. HYPOthyroidism
  2. Nausea / Diarrhea
  3. Tremor
  4. Decreased [] and sedation
    5 Weight gain
40
Q

Serious side effects of Li?

A
  1. Nephrogenic diabetes insipidus
  2. Renal insufficiency
  3. End stage renal disease: rare
41
Q

How to treat sever LI toxicity?

A

Dialysis

42
Q

Lab tests for patients on Li?

A
  1. TSH
  2. Renal Function
  3. Pregnancy test
  4. ECG if > 50 yo
  5. Li level every 6 - 12 months
43
Q

Trade names for valproic acid and divalproex sodium?

A

Valproic acid: Depakene

Dival proex Na: Depakote

44
Q

Difference between depakote and depakene?

A

Depakene: Original version, high prevalence of nausea / vomiting
Depakote: powdered form with “kote,” less GI effects

45
Q

MOAs of depakene /kote?

A
  1. GABA reuptake inhibitor
  2. 2nd messenger enzyme influencer
  3. Blockage of voltage dependent Na Channels
46
Q

Kinetics of depakote?

A

100% Absorption
90% protein bound
12 Hour 1/2 life

47
Q

What drugs can displace depakote from protein binding?

A
  1. Caffeine

2. Asparin

48
Q

DDIs of depakote?

A
  1. Inhibit hepatic metabolism of drugs
  2. Displace drugs from protein: Phenytoin
  3. Displaced by drugs: aspirin / caffeine
49
Q

MOA for depakote causing hepatic toxicity of other drugs?

A
  • Inhibits phase II glucuronidation pathway

* ***Does NOT involve CYP450 system

50
Q

Drugs depakote causes hepatic toxicity in?

A
  1. Phenytoin
  2. Carbamazepine
  3. Lamotrigine
51
Q

Drugs depakote displaces?

A
  1. Phenytoin
  2. Carbamazepine
  3. Diazepam
52
Q

Depakote side effects?

A
  1. Nausea / vomiting / diarrhea
  2. Tremor
  3. Sedation
  4. Weight gain
  5. Thrombocytopenia: check platelet levels
  6. Increased ammonia levels
53
Q

Depakote toxicity?

A
  1. Increased LFTs (Liver Function Tests)

2. Hepatotoxicity: Kids

54
Q

What type of drug is depakote?

A

Mood stabilizer / anticonvulsant

55
Q

What to monitor while patient on depakote?

A
  1. LFTs
  2. Platelets: thrombocytopenia
  3. Pregnancy
  4. [Depakote] - hit correct windows
56
Q

MOAs of carbamazepine?

A
  1. Decrease Na influx depressing synaptic transmission
  2. Adenosine agonist
  3. Decrease NE / glutamate release
57
Q

Kinetics of carbamazepine?

A
  1. Erratic absorption

2. 70 - 80 % Protein binding: wont know off much

58
Q

DDIs of carbamazepine?

A
  1. INDUCES CYP450s increasing self and other drug absorption
  2. Induces UDP glucuronosyltransferase
  3. Other drugs can increase or decrease its metabolism
  4. CANNOT slow down other drug metabolism
59
Q

Difference between depakote and carbamazepine effect on glucuronidation pathway?

A

Depakote: INHIBITS pathway
Carbamazepine: INDUCES pathway

60
Q

Side effects of carbamazepine?

A
  1. Nausea
  2. Dizziness
  3. Sedation
  4. Teratogen: Neural tube defects
  5. Steven Johnsons Syndrome
  6. Aplastic anemia`
  7. Agranulocytosis
  8. Weight Gain
  9. Increased Suicide Risk
61
Q

What are the mood stabilizers?

A
  1. Depakote
  2. Lamotrigine
  3. Carbamazepine
62
Q

Indications of lamotrigine?

A
  1. Bipolar depression
  2. Bipolar maintenance
  3. NOT useful for manic episodes
63
Q

Lamotrigine MOA?

A
  1. Inhibition of Na Channels

2. Inhibits glutamate release

64
Q

Lamotrigine kinetics?

A
  1. Metabolized by glucuronidation

2. Low protein binding

65
Q

What is inhibition of Na channels useful in?

A

Anti epileptic effect

66
Q

Which drug inhibits glucuronidation?

A

Depakote

67
Q

DDIs of lamotrigine?

A
  1. Depakote: 2x lamotrigine levels
  2. Oral contraceptives: 1/2 lamotrigine levels
  3. Carbamazepine: 1/2 lamotrigine levels
68
Q

What do do when patient is on depakote and you need to put on lamotrigine?

A

Cut lamotrigine dose in half

69
Q

Lamotrigine side effects?

A
  1. Benign Rash: must assume steven Johnsons
  2. Steven Johnsons syndrome: rarer
  3. Nausea
    * **Alcohol can increase severity
70
Q

What is stephen Johnsons syndrome?

A
  • Toxic epidermal necrolysis, (life-threatening condition) in which cell death causes epidermis to separate from dermis. - Hypersensitivity complex that affects the skin and the mucous membranes
  • ***Lamotrigine
71
Q

Drug to look out for Steven Johnson syndrome with?

A

Lamotrigine

72
Q

What are SGAs?

A

“Second Generation Antipsychotics”

73
Q

When is mania considered severe?

A
  1. Patient is psychotic
  2. Patient is suicidal
  3. Patient puts others in danger
    * **Usually situations when patient is hospitalized
74
Q

When and how are SGAs used to treat bipolar disorder?

A
  • In severe mania when patient would be hospitalized

- In conjunction with Li or Depakote

75
Q

Pregnancy risk of Li?

A
  1. Ebstein’s anomaly in first trimester (cardiac)

* **Risk thought to be much lower than commonly believed

76
Q

Which bipolar med has greatest risk for birth defect?

A

Valproic acid

77
Q

Pregnancy risk of depakote?

A

Neural tube defects: highest risk of all antipsychotics

78
Q

Risk of carbamazepine in pregnancy?

A

Neural tube defects: less than depakote

79
Q

Risk of lamotrigine in pregnancy?

A

Possible cleft pallet

**Least risk of all

80
Q

Which stages of bipolar disorder does Li treat?

A
  1. Acute mania
  2. Maintenance
  3. Depression
81
Q

Which stages of bipolar disorder does Depakote treat?

A
  1. Acute mania

2. Maintenance

82
Q

Which stages of bipolar disorder does carbamazepine treat?

A
  1. Acute mania

2. Maintenance

83
Q

Which stages of bipolar disorder does Lamotrigine treat?

A
  1. Depression

2. Maintenance