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TN Psychiatry > 22.3 Pharmacotherapy: Mood stabilizers > Flashcards

22.3 Pharmacotherapy: Mood stabilizers Flashcards

1
Q

Name examples of mood stabilizers (4)

A
  • Lithium
  • Divalproex (Epival®)
  • Lamotrigine (Lamictal®)
  • Carbamazepine (Tegretol®)
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2
Q

Describe use of mood stabilizers (2)

A
  • used as first-line monotherapy or in conjunction with atypical antipsychotics for acute episodes of
    • bipolar disorder
    • depression
    • mania
    • or for long-term stabilization
  • vary in their ability to “treat” (reduce symptoms acutely) or “stabilize” (prevent relapse and recurrence) manic and depressive symptoms; multi-agent therapy can be avoided in many patients but it is common
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3
Q

What to do before starting mood stabilizers? (12)

A
  • before initiating, get baseline:
    • CBC with diff and platelets
    • ECG (if patient >45 yr old or cardiovascular risk)
    • BUN
    • Cr
    • electrolytes
    • TSH
  • Also:
    • screen for pregnancy
    • thyroid disease
    • neurological
    • renal
    • liver
    • cardiovascular diseases
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4
Q

Full effects of mood stabilizers take how long? (1)

A
  • full effects may take 2-4 wk, thus may need acute coverage with benzodiazepines or antipsychotics
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5
Q

Name rx for rapid cycling bipolar disorder

A
  • Divalproex (Epival®)
  • Carbamazepine (Tegretol®)
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6
Q

Name rx for acute mania (4)

A
  • Lithium
  • Divalproex (Epival)
  • Carbamazepine (Tegretol®)
  • NOT recommended: Lamotrigine (Lamictal)
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7
Q

Describe mode of action: Lithium (1)

A
  • Unknown
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8
Q

Therapeutic response when with Lithium? (1)

A

Therapeutic response within 7-14 d

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9
Q

Describe dosage: Lithium (3)

A
  • Adult: 600-1500 mg/d
  • Geriatric: 150-600 mg/d
  • Usually daily dosing
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10
Q

Describe therapeutic level: Lithium (2)

A
  • Adult: 0.8-1.0 mmol/L (1.0-1.25 mmol/L for acute mania)
  • Geriatric: 0.6-0.8 mmol/L
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11
Q

Describe monitoring: Lithium (4)

A
  • Monitor serum levels every 5-7 d until therapeutic (always wait 12 h after dose)
  • Then monitor monthly, then q2-3mo
  • Thyroid function, creatinine q6mo
  • Urinalysis q1yr
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12
Q

Name side effects: Lithium (18)

A
  • GI:
    • N/V
    • Diarrhea
    • Stomach pain
  • GU:
    • Polyuria, polydipsia
    • Nephrogenic DI, GN, renal failure
  • CNS:
    • Fine tremor
    • Headache
    • Fatigue
    • Lethargy
  • Hematologic: reversible benign leukocytosis
  • Other:
    • Teratogenic (Ebstein’s anomaly)
    • Hypothyroidism
    • Weight gain
    • Edema
    • Psoriasis
    • Muscle weakness
    • Bradycardia
    • ECG changes
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13
Q

Describe interactions: Lithium (4)

A
  • NSAIDs
  • Thiazides
  • ACE inhibitors
  • Metronidazole

decrease clearance, risk for lithium toxicity

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14
Q

Describe mode of action: Lamotrigine (Lamictal®) (2)

A
  • May inhibit 5-HT3 receptors
  • May potentiate DA activity
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15
Q

Describe dosage: Lamotrigine (Lamictal®) (3)

A
  • Note: very slow titration required due to risk of Stevens-Johnson Syndrome
  • Dose adjusted in patients taking other anticonvulsants
  • Daily dose: 100-200 mg/d
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16
Q

Describe therapeutic level: Lamotrigine (Lamictal®) (2)

A
  • Therapeutic plasma level not established
  • Dosing based on therapeutic response
17
Q

Describe monitoring: Lamotrigine (1)

A

Monitor for skin rash and suicidality, when initiating treatment

18
Q

Name side effets: Lamotrigine (Lamictal®) (9)

A
  • Skin: rash (consider discontinuing due to risk of Steven-Johnson syndrome), slow dose titration to reduce risk
  • Otherwise, usually well tolerated
  • GI: N/V, diarrhea
  • CNS:
    • ataxia
    • dizziness
    • diplopia
    • headache
    • somnolence
  • Other: anxiety
19
Q

Describe mode of action: Divalproex (Epival®) (2)

A
  • Depresses synaptic transmission
  • Raises seizure threshold
20
Q

Describe dosage: Divalproex (Epival®) (2)

A
  • 750-2500 mg/d
  • Usually daily dosing with ER preparation
21
Q

Describe therapeutic level: Divalproex (Epival®) (2)

A
  • 17-50 mmol/L
  • Same therapeutic levels as used for seizure prophylaxis
22
Q

Describe monitoring: Divalproex (Epival®) (3)

A
  • Monitor serum levels every 5-7 d until therapeutic
  • LFTs weekly x 1 mo, then monthly, then q2-3mo due to risk of liver dysfunction
    • Watch for signs of liver dysfunction: nausea, edema, malaise
  • Check platelets and monitor levels to adjust dosage and confirm adherence
23
Q

Name side effets: Divalproex (Epival®) (10)

A
  • GI: liver dysfunction, N/V, diarrhea
  • CNS:
    • ataxia
    • drowsiness
    • tremor
    • sedation
    • cognitive blurring
  • Other:
    • hair loss
    • weight gain
    • thrombocytopenia
    • neural tube defects when used in pregnancy
24
Q

Describe interactions: Divalproex (Epival®) (1)

A

OCP

25
Q

Describe mode of action: Carbamazepine (Tegretol®) (2)

A
  • Depresses synaptic transmission
  • Raises seizure threshold
26
Q

Describe dosage: Carbamazepine (Tegretol®) (2)

A
  • 400-1600 mg/d
  • Usually bid or tid dosing
27
Q

Describe therapeutic level: Carbamazepine (Tegretol®) (2)

A
  • 350-700 μmol/L
  • Same therapeutic levels as used for seizure prophylaxis
28
Q

Describe monitoring: Carbamazepine (Tegretol®) (3)

A
  • Monitor serum levels every 5-7 d until therapeutic
  • Weekly blood counts for 1st mo, due to risk of agranulocytosis
  • Watch for signs of blood dyscrasias:
    • fever
    • rash
    • sore throat
    • easy bruising
29
Q

Name side effets: Carbamazepine (Tegretol®) (10)

A
  • GI:
    • N/V, diarrhea
    • hepatic toxicity
  • CNS:
    • ataxia, dizziness, slurred speech, drowsiness, confusion
    • nystagmus
    • diplopia
  • Hematologic:
    • transient leukopenia (10%)
    • rare agranulocytosis
    • aplastic anemia
  • Skin: rash (5% risk; consider discontinuing drug because of risk of Stevens-Johnson syndrome)
  • Other: neural tube defects when used in pregnancy
30
Q

Describe interactions: Carbamazepine (Tegretol®) (1)

A

OCP

31
Q

Describe dx: Lithium toxicity

A

clinical dx, can occur at therapeutic levels

32
Q

Name common causes: Lithium Toxicity (5)

A
  • overdose
  • sodium/fluid loss
  • concurrent medical illness
  • initiation of NSAIDs
  • diuretics
33
Q

Name clinical features: Lithium Toxicity (11)

A
  • GI: severe nausea/vomiting and diarrhea
  • cerebellar:
    • ataxia
    • slurred speech
    • lack of coordination
  • cerebral:
    • drowsiness
    • myoclonus
    • tremor
    • upper motor neuron signs
    • seizures
    • delirium
    • coma
34
Q

Describe management: Lithium Toxicity (4)

A
  • discontinue lithium for several days and begin again at a lower dose when lithium level has fallen to a non-toxic range
  • monitor serum lithium levels, BUN, electrolytes
  • IV saline
  • hemodialysis possible
35
Q

Name indications dialysis: Lithium Toxicity (6)

A
  • lithium >2 mmol/L
  • coma
  • shock
  • severe dehydration
  • failure to respond to tx after 24 h
  • deterioration

TN Psychiatry (26 decks)

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