22.3 Pharmacotherapy: Mood stabilizers Flashcards
Name examples of mood stabilizers (4)
- Lithium
- Divalproex (Epival®)
- Lamotrigine (Lamictal®)
- Carbamazepine (Tegretol®)
Describe use of mood stabilizers (2)
- 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
What to do before starting mood stabilizers? (12)
- 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
Full effects of mood stabilizers take how long? (1)
- full effects may take 2-4 wk, thus may need acute coverage with benzodiazepines or antipsychotics
Name rx for rapid cycling bipolar disorder
- Divalproex (Epival®)
- Carbamazepine (Tegretol®)
Name rx for acute mania (4)
- Lithium
- Divalproex (Epival)
- Carbamazepine (Tegretol®)
- NOT recommended: Lamotrigine (Lamictal)
Describe mode of action: Lithium (1)
- Unknown
Therapeutic response when with Lithium? (1)
Therapeutic response within 7-14 d
Describe dosage: Lithium (3)
- Adult: 600-1500 mg/d
- Geriatric: 150-600 mg/d
- Usually daily dosing
Describe therapeutic level: Lithium (2)
- Adult: 0.8-1.0 mmol/L (1.0-1.25 mmol/L for acute mania)
- Geriatric: 0.6-0.8 mmol/L
Describe monitoring: Lithium (4)
- 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
Name side effects: Lithium (18)
- 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
Describe interactions: Lithium (4)
- NSAIDs
- Thiazides
- ACE inhibitors
- Metronidazole
decrease clearance, risk for lithium toxicity
Describe mode of action: Lamotrigine (Lamictal®) (2)
- May inhibit 5-HT3 receptors
- May potentiate DA activity
Describe dosage: Lamotrigine (Lamictal®) (3)
- 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
Describe therapeutic level: Lamotrigine (Lamictal®) (2)
- Therapeutic plasma level not established
- Dosing based on therapeutic response
Describe monitoring: Lamotrigine (1)
Monitor for skin rash and suicidality, when initiating treatment
Name side effets: Lamotrigine (Lamictal®) (9)
- 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
Describe mode of action: Divalproex (Epival®) (2)
- Depresses synaptic transmission
- Raises seizure threshold
Describe dosage: Divalproex (Epival®) (2)
- 750-2500 mg/d
- Usually daily dosing with ER preparation
Describe therapeutic level: Divalproex (Epival®) (2)
- 17-50 mmol/L
- Same therapeutic levels as used for seizure prophylaxis
Describe monitoring: Divalproex (Epival®) (3)
- 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
Name side effets: Divalproex (Epival®) (10)
- 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
Describe interactions: Divalproex (Epival®) (1)
OCP
Describe mode of action: Carbamazepine (Tegretol®) (2)
- Depresses synaptic transmission
- Raises seizure threshold
Describe dosage: Carbamazepine (Tegretol®) (2)
- 400-1600 mg/d
- Usually bid or tid dosing
Describe therapeutic level: Carbamazepine (Tegretol®) (2)
- 350-700 μmol/L
- Same therapeutic levels as used for seizure prophylaxis
Describe monitoring: Carbamazepine (Tegretol®) (3)
- 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
Name side effets: Carbamazepine (Tegretol®) (10)
- 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
Describe interactions: Carbamazepine (Tegretol®) (1)
OCP
Describe dx: Lithium toxicity
clinical dx, can occur at therapeutic levels
Name common causes: Lithium Toxicity (5)
- overdose
- sodium/fluid loss
- concurrent medical illness
- initiation of NSAIDs
- diuretics
Name clinical features: Lithium Toxicity (11)
- GI: severe nausea/vomiting and diarrhea
- cerebellar:
- ataxia
- slurred speech
- lack of coordination
- cerebral:
- drowsiness
- myoclonus
- tremor
- upper motor neuron signs
- seizures
- delirium
- coma
Describe management: Lithium Toxicity (4)
- 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
Name indications dialysis: Lithium Toxicity (6)
- lithium >2 mmol/L
- coma
- shock
- severe dehydration
- failure to respond to tx after 24 h
- deterioration
