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PHRM 845 > 5.2 Pharmacotherapy of bipolar disorder > Flashcards

5.2 Pharmacotherapy of bipolar disorder Flashcards

1
Q

What are comorbidities of bipolar disorder?

A
  • Alcohol and substance use common
  • Anxiety disorders are common comorbidities and can significantly impact remission of mood episodes if left untreated or inadequately treated
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2
Q

What other disease is experienced most often in bipolar disorder?

A

Depression
- Can lead to misdiagnosis

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3
Q

How does the DSM5 define bipolar 1 disorder?

A
  • > = 1 manic episodes
  • Depressive or hypomanic episode may have occurred
  • Manic episodes generally last >= 1 week
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4
Q

How does the DSM5 define bipolar 2 disorder?

A
  • Major depressive and hypomanic episodes
  • Hypomanic episodes generally last >= 4 days
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5
Q

What is 1st line for bipolar disorder?

A

Mood stabilizers are foundation of acute and maintenance tx:
- Usually lithium or valproic acid
- (Atypicals can also be 1st line, as monotherapy or in combo w lithium or valproic acid)

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6
Q

What is the therapeutic index of lithium?

A

Narrow

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7
Q

What is lithium associated with?

A

Associated with decrease in suicidality

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8
Q

What are the levels of lithium for it to be a mild to severe toxicity? What must be thought about if it reaches these levels?

A

1.5 - >3.0 mEq/L:
- Think about renal fxn, possible hemodialysis

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9
Q

What are toxicities of lithium?

A
  • GI
  • Ataxia
  • Coarse hand tremor
  • Altered mental status
  • Seizure
  • Lethargy
  • Confusion, agitation
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10
Q

What are the SEs of lithium?

A
  • Fine hand tremor
  • Hypothyroidism
  • Polyuria, polydipsia
  • Acne
  • Dry mouth
  • Weight gain
  • ECG changes
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11
Q

What teratogenic effects does lithium have?

A

Cardiac structural abnormality (Ebstein’s anomaly)

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12
Q

When should lithium be avoided and used w caution during pregnancy?

A
  • AVOID during 1st trimester
  • Use w caution in 2nd and 3rd trimester
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13
Q

What are laboratory monitoring parameters of lithium?

A
  • SCr, BUN (lithium is almost entirely renally excreted)
  • Na (important), K, Ca
  • ECG (esp if >40 yo or CV risk factors)
  • TSH, T4
  • Parathyroid hormones
  • CBC w differential
  • Weight
  • Pregnancy test
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14
Q

What are the drug interactions associated w lithium?

A
  • Decrease Li renal clearance w ACEi, ARBs, thiazide diuretics, NSAIDs, dehydration
  • Increased Li renal clearance w caffeine, osmotic diuretics, +/- w loops, Na bicarb, high Na intake
  • Toxicity related to Na depletion through thiazides
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15
Q

What is an issue w valproate associated w its dosage forms?

A

Available in several dosage forms –> risk for med errors

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16
Q

What is the difference between the valproate ER and DR dosage forms?

A

ER dosage form is 10-15% less bioavailable than DR dosage form

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17
Q

What is the conversion between the valproate ER and DR dosage forms?

A

1:1 conversion, expect lower serum conc w ER (not clinically significant)

18
Q

What can valproic acid syrup (IR) and capsule sprinkle form have a risk of?

A

Higher risk for GI ulcerations (usually esophageal)

19
Q

What are the optimal serum levels of valproate for most efficacy?

A

Serum levels 80-125 mcg/ml has most efficacy for mania

20
Q

When should the optimal serum levels of valproate be achieved?

A

Obtain level at least 96 hours (4 days) after 1st dose or dose increase

21
Q

Is valproic acid teratogenic? What are the teratogenic effects?

A

Yes
- Unsafe in any trimester of pregnancy; obtain baseline pregnancy test
- Neural tube defects, lower IQ in offspring

22
Q

What can valproic acid commonly cause in women?

A

Polycystic ovarian syndrome occurs in up to 50% of women

23
Q

What are the AEs of valproic acid?

A
  • GI: anorexia, N/V/D, dyspepsia, ulceration
  • Thrombocytopenia, platelet dysfxn
  • Increased appetite: weight gain of 6-8 kg
  • Hyperammonemia
24
Q

What are the laboratory monitoring parameters of valproic acid?

A
  • Baseline: pregnancy test, LFTs, CBC w differential
  • Valproate serum conc
  • Serum ammonia if suspect hyperammonemia; otherwise routine monitoring not necessary
25
Q

What are the drug interactions w valproic acid?

A
  • Significant concern w combo use w lamotrigine: increased lamotrigine serum conc increases risk of Stevens-Johnson syndrome
26
Q

What are the other mood stabilizers?

A
  • Carbamazepine (Tegretol)
  • Oxcarbazepine (Trileptal)
  • Lamotrigine (Lamictal)
  • Topiramate (Topamax)
27
Q

What is carbamazepine (tegretol) assocated w?

A
  • Thombocytopenia/ hematologic effects
  • Teratogenic
28
Q

What type of inducer is oxcarbazepine (trileptal)?

A

CYP450 3A4 inducer (NO auto-induction)

29
Q

What is oxcarbazepine (trileptal) associated w?

A

Hyponatremia

30
Q

When is lamotrigine (lamictal) 1st line?

A
  • 1st line tx for DEPRESSIVE sxs in bipolar disorder
  • NOT useful for acute tx or for manic episodes
31
Q

What titration process must be used for lamotrigine (lamictal) and why?

A
  • Slow dose-titration for risk of Stevens-Johnson syndrome
  • Retitrate if non-adherence for >= 3-5 days
32
Q

What are SE/AEs of topiramate (topamax)?

A
  • May cause weight loss
  • Heat intolerance/ hypohidrosis
  • Metabolic acidosis and kidney stones
  • Possible teratogen: cardiac structural defects
33
Q

Which atypicals are NOT FDA approved for bipolar disorder?

A
  • Brexpiprazole
  • Clozapine
  • Iloperidone
  • Paliperidone
34
Q

For the FDA approved atypicals, what are they specifically approved for in bipolar disorder?

A

FDA approved for acute and/or maintenance tx (manic/mixed episodes) w or w/o psychosis

35
Q

What is quetiapine (seroquel), olanzapine/fluoxetine (symbyax), and lurasidone (latuda) approved for?

A

FDA approved for bipolar depression

36
Q

What is aripiprazole (abilify) approved for?

A

FDA approved for adjunctive tx in depression in combo w antidepressant tx

37
Q

What are the tx considerations of bipolar disorder meds?

A
  • Mood stabilizer tx is longer-term and considered to be maintenance tx to reduce time to subsequent mood episodes
  • Suicide attempt risk is high in both poles of bipolar disorder: monitor closely, use lithium cautiously
38
Q

Due to teratogenic effects, what are considered 1st line during pregnancy?

A

Atypicals like olanzapine and clozapine

39
Q

What is the use of antidepressants linked with?

A

Linked w a switch to mania

40
Q

What is required as adjunct w antidepressant therapy for bipolar disorder?

A

Need to have maintenance mood stabilizer therapy in combo w antidepressant therapy

41
Q

What is a common co-morbidity in bipolar disorder and how is it treated?

A
  • Anxiety disorders
  • Use serotonergic antidepressants to tx anxiety
42
Q

What is preferred to use for bipolar disorder?

A

Prefer to use mood stabilizers that target the depressive pole:
- Lamotrigine, lithium, lurasidone, quetiapine

PHRM 845 (48 decks)

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