56. Bipolar Disorder Flashcards
A pharmacist will counsel a patient beginning lamotrigine therapy for bipolar disorder. Which of the following statements regarding lamotrigine are correct? (Select ALL that apply.)
A. When you start this medication, you will need to slowly increase the dose; that’s why it comes in a dosing packet.
B. Do not take other medicines or over-the-counter products without discussing them first with your doctor or pharmacist.
C. If you develop a rash that quickly becomes serious; do not take more than prescribed and see your doctor right away if this happens, or if the doctor is not available to consult with you, get emergency medical help.
D. This medicine can cause you to feel somewhat dizzy and tired.
E. The brand name of this medicine is Latuda.
A, B, C, D. The brand name of lamotrigine is Lamictal.
A pharmacist will counsel a patient beginning lithium therapy for bipolar disorder. Which of the following statements regarding lithium are correct? (Select ALL that apply.)
A. You should not become pregnant while taking this medicine; it is likely to harm the baby, but if you do, contact your doctor right away.
B. It is helpful to get lots of sun to help improve your mood when using this medicine.
C. This medication can cause a light tremor in your hands; if you notice the tremor looks worse (much more noticable), it can mean the level of drug in your body is too high and you should see the doctor right away.
D. Prepared frozen food, fast food and Chinese food usually contain a lot of salt; the salt in your diet needs to be about the same amount every day, so you need to think about what you are eating.
E. This medication can make your weight go up; it is helpful to get exercise, such as walking, and stay away from sweets and sugary drinks.
A, C, D, E. With lithium, do not change the amount of salt consumed. Do not stay in the sun for long periods.
In the past few years, drugs typically used for schizophrenia have been used for bipolar disorder. Which of the following antipsychotics can raise prolactin levels, with increased risk at higher doses? (Select ALL that apply.)
A. Invega
B. Equetro
C. Stavzor
D. Lithobid
E. Risperdal
A, E. Risperidone (Risperdal) and paliperidone (Invega) are associated with increase in prolactin levels. Paliperidone does not have the indication for bipolar but may be used off-label for this condition.
A patient received a prescription for asenapine. Choose the correct statement concerning asenapine. (Select ALL that apply.)
A. Formulations of asenapine include an oral solution and tablets.
B. Asenapine can make the mouth numb.
C. Asenapine has little QT risk and can safely be used with cardiovascular conditions.
D. The brand name is Saphire.
E. Patients should be counseled to avoid driving when initiating or titrating therapy.
B, E. Asenapine comes in a sublingual formulation which must be dissolved under the tongue and can cause mouth numbness.
A patient has been diagnosed with bipolar II disorder. Which of the following statement concerning bipolar disorder is correct?
A. The mania symptoms are generally worse in bipolar II than in bipolar I.
B. The depressive symptoms are generally worse in bipolar II than in bipolar I.
C. Bipolar II is much less common than bipolar I.
D. Bipolar II is much more common in men.
E. In bipolar I, mania and psychosis can require hospitalization.
E. Bipolar I disorder is the most severe version of the disorder. When patients are in a manic episode or experiencing psychosis, hospitalization may frequently be required. Bipolar II disorder is characterized by hypomanic episodes which are less severe where the patient can still function and does not require hospitalization.
A pharmacist will counsel a patient beginning valproic acid therapy for bipolar disorder. Which of the following statements regarding valproic acid are correct? (Select ALL that apply.)
A. In rare cases this drug can cause damage to your liver. If you feel very tired and lose your appetite, or if your stool becomes light in color (or your skin becomes yellowish), you need to be seen by your doctor right away.
B. You should not become pregnant while using this medicine. If you do become pregnant, see the doctor right away.
C. In rare cases this drug can cause damage to your pancreas. If you become nauseated, with a loss of appetite and pain around your abdomen (stomach area), you need to be seen by your doctor right away.
D. This medication can cause the cells that fight infection to become very low. You need to watch for symptoms of having an infection, such as feeling weak and tired, or running a fever. If this happens you should see your doctor as soon as possible.
E. Take this medicine on an empty stomach.
A, B, C. Valproic acid does not cause agranulocytosis. Carbamazepine has this risk. Valproate causes stomach upset and is easier to tolerate if taken with food.
A patient gave the pharmacist a prescription for Depakene 150 mg BID #60. Which of the following is an appropriate generic substitution for Depakene?
A. Quetiapine
B. Lithium
C. Carbamazepine
D. Divalproex
E. Valproic acid
E. The generic name of Depakene is valproic acid.
Side effects of divalproex sodium may include: (Select ALL that apply.)
A. GI upset
B. Alopecia
C. Sedation
D. Iron overload
E. Weight Loss
A, B, C. Patients should be counseled regarding the possibility of GI upset, alopecia (which is hair loss - may be preventable with selenium and zinc supplementation), sedation, tremor and weight gain. This is one of the drugs with significant weight gain, which can contribute to nonadherence.
A pharmacist will counsel a patient beginning lithium therapy for bipolar disorder. Which of the following statements regarding lithium are correct? (Select ALL that apply.)
A. In rare cases this drug can cause damage to your liver. If you feel very tired and lose your appetite, or if your stool becomes light in color (or your skin becomes yellow-ish), you need to be seen by your doctor right away.
B. You should not become pregnant while using this medicine. If you do become pregnant, see the doctor right away.
C. If you feel very nauseated, or if your stools are loose and watery, and if you feel confused (with slurring speech, or trouble walking, it could mean the amount of medicine in your body is too high and you will need to see the doctor right away.
D. This medicine can make you feel thirsty, and then you will need to use the bathroom more often. In order to prevent becoming dehydrated, drink water often and take a water bottle with you when you go out.
E. Take this medicine on an empty stomach one hour before or two hours after meals.
B, C, D. Lithium causes stomach upset and is taken with food; otherwise it can be difficult to tolerate.
What is the correct serum trough range for monitoring lithium therapy?
A. 0.1-0.5 mg/L
B. 1-1.2 mEq/L
C. 0.4-1.2 mcg/mL
D. 0.6-1.2 mEq/L
E. 5-10 mg/L
D. Lithium, along with some electrolytes, is measured in milliequivalents (mEq). Most drugs are measured in mg/L, which is the same as mcg/mL. In treating an acutely manic patient, the clinician may go slightly above this level for a short-time period, and then lower the dose to stay within this range.
Bipolar disorder can aggravate or cause the following behaviors: (Select ALL that apply.)
A. Tics and other vocal outbursts
B. Excessive gambling
C. Risky sexual behaviors
D. Higher risk of suicide
E. Trouble at work due to poor performance
B, C, D, E. Tics and other vocal outbursts may be present as a comorbid disorder but are not associated with bipolar directly.
Choose the correct descriptions concerning lithium, carbamazepine and valproic acid use in pregnancy:
A. They are rated Pregnancy Category B.
B. They are rated Pregnancy Category C.
C. They are rated Pregnancy Category X.
D. These drugs are known to cause birth defects; they should only be used if the benefit clearly outweighs the risk.
E. These drugs are safe to use in pregnancy.
D. These three agents are Pregnancy Category D; they are known teratogens and should only be chosen if the benefit outweighs the risk. Lamotrigine and quetiapine, which are both increasingly used for bipolar disorder, are Pregnancy Category C. Valproate formulations are Pregnancy Category X for migraine (they cannot be used for migraine).
JS is a 43 year-old black female with bipolar disorder who has been using lithium for 4 1/2 years. She presents to the clinic to complain about nausea. She says that as she has gotten older, her nausea has worsened and she noticed how bad it was during a recent trip to Disneyland. She couldn’t enjoy any of the rides. The nausea is particularly bad when her brother is driving the car because he “jerks.” Her current lithium level is 0.9 mEq/L. She presents with mild tremor and bilateral cogwheel rigidity. Patient reports “good” mood and states she is “fine” with lithium. Pharmacy records indicate good adherence. JS says that she takes Tums for the nausea, but it doesn’t help as much as it used to and asks for something stronger. JS reports that she eats two primary meals per day (lunch and dinner) and rarely has breakfast except some coffee +/-juice.
Medications
Lithium carbonate 300 mg TID, with meals.
B-vitamin “energy” complex
Valerian for “nerves” as-needed
Vitals: BP 118/80, HR 74, Temp: 37.1 C
Height: 5’6”, Wt: 72 kg
Which of the following represents a reasonable option for JS at this time?
A. Counsel patient to immediately discontinue the coffee and begin to take Reglan.
B. Change to Symbyax.
C. Change to Seroquel XR.
D. Change to Eskalith CR 450 mg BID, recommend eating some breakfast.
E. Change to valproate for bipolar control; as she ages she should be weaned off lithium.
D. The lithium is working for the patient; she should not be encouraged to switch medications. Her renal function is hopefully being monitored. She can switch to a long-acting formulation and take the doses with food. Even with some toast and water, or ginger ale, can help. Make sure she is consuming adequate fluids; this is required with lithium in all patients. In some patients lower fluid intake will worsen nausea.
In the past few years, drugs typically used for schizophrenia have been approved for various states of bipolar. Which of the following drugs can be used for bipolar disorder (various states), according to the FDA-indications? (Select ALL that apply.)
A. Thioridazine
B. Haloperidol
C. Asenapine
D. Quetiapine
E. Aripiprazole
C, D, E. Antipsychotics have various indications and are used for bipolar depression, or for mania, or for mixed episodes, either alone or with other agents in combination. It would have been a good guess that the older agents that cause significant ADRs would not get this approval: thioridazine due to QT prolongation, and haloperidol due to movement disorders.
What are the indications for Symbyax? (Select ALL that apply.)
A. Treatment of tics due to Tourette’s or other conditions
B. Treatment-resistant depression
C. Bipolar depression
D. Antipsychotic-induced metabolic syndrome
E. Fibromyalgia
B, C. Antipsychotics are sometimes used in low doses in addition to antidepressants for treatment-resistant depression (as is seen with this combo drug) and could be useful for depression (which is similar to major depressive disorder) with bipolar disorder.
