65. Bipolar Disorder Flashcards
Bipolar classifications and definitions: Bipolar I
at least 1 episode of mania, and usually, bouts of intense depression (depressive episode is not required for dx)
Mania is a/w with at least 1 of the following: sig impairment in social/work functioning, psychosis/delusions, or requires hospitalization
Bipolar classifications and definitions: Bipolar II
At least 1 episode of hypomania (lasting ≥4 consecutive days) and at least 1 depressive episode (lasting ≥2 weeks)
Hypomania does NOT affect social/work functioning, dose not cause psychosis not require hospitalization
Bipolar disorder is characterized by ___
fluctuations in mood from an extremely sad or hopeless state to an abnormally elevated, overexcited, or irritable mood called mania or hypomania (milder)
Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by the severity of ____
mania experienced
DSM-5 criteria for mania
Abnormally elevated or irritable mood for at least 1 week (or any duration if hospitalization is needed)
≥ 3 symptoms (if mood is only irritable, exhibits ≥ 4 symptoms):
- inflated self-esteem
- needs less sleep
- more talkative than normal
- jumping from topic to topic
- easily distracted
- increased in goal-directed activity
- high-risk, pleasurable activities (E.g. buying sprees, sexual indiscretions, gambling)
The goal of bipolar treatment is to ___
stabilize mood without inducing depressive or manic state
Traditional mood stabilizers, such as ____ , treat both mania and depression without inducing either state
lithium and antiepileptic drugs (valproate, lamotrigine, and carbamazepine)
Antipsychotics, while not traditional mood stabilizers, can stabilize mood when amnia occurs with ___.
psychosis
Antidepressants can induce or exacerbate ___ episode if used as monotherapy, so should only be used in combo with _____ for bipolar treatment
manic
mood stabilizer
When selecting treatment for bipolar disorder, what should you consider?
side effect profile
pt’s med history and first-degree relatives’ med hx - if pt or fam member responded well to a drug, same drug might be reasonable option
Drug formulations available and cost
Acute treatment for manic episode
antipsychotic (e.g. olanzapine, risperidone), lithium, or valproate
Combo of antipsychotic + lithium or valproate is preferred for severe episodes
Acute treatment of depressive episode
First line treatment is antipsychotic (e.g. quetiapine, lurasidone)
Lithium, valproate, or lamotrigine can be added or used as alternatives
Maintenance treatment for bipolar disorder
medications that were effective for acute episodes should be continued to avoid relapse
These include, lithium, antiepileptic drugs, and SGAs
Combo might be more effective than monotherapy at preventing relapse
Why are MedGuides required with all antidepressants and antipsychotics?
Antidepressants = primarily d/t suicide risk
Antipsychotics = d/t increased risk of death in elderly pts with dementia-related psychosis
Lamotrigine (Lamictal, Lamictal ODT, Lamictal XR, Lamictal starter kit) requires slow titration d/t risk of ___. do not use for acute mania
severe rash
Examples of antiepileptic drugs used in bipolar disorder
lamotrigine (Lamictal)
Valproate/valproic acid derivatives (Depakote)
Carbamazepine (Equetro)
Which SGAs are used in bipolar disorder?
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Lurasidone (Latuda) - can use alone or in combo with mood stabilizers for bipolar depressive episodes
Olanzapine/fluoxetine (Symbyax) - can use alone for acute depresive episodes
Therapeutic range of lithium (Lithobid)
0.6-1..2 mEq/L (trough)
Warnings for lithium (Lithobid)
Serotonin syndrome
Renal impairment, hyponatremia, and dehydration (increased lithium tox)
Side effects of lithium (within therapeutic range)
GI upset, cognitive effects, cogwheel rigidity, fine hand tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism
Others: hypercalcemia, cardiac abnormalities, edema, anorexia, worsening psoriasis, blue-gray skin pigmentation, impotence
Side effects of lithium toxicity > 1.5 mEq/L
ataxia, coarse hand tremor, vomiting, persistent diarrhea, confusion, sedation
Side effects of lithium toxicity > 2.5 mEq/L
CNS depression, arrhythmia, seizure, coma
Monitoring for lithium
Serum lithium levels (trough), renal function, thyroid function (TSH, FT4), electrolytes (Ca, K, Na)
How is lithium cleared?
renally cleared
No CYP450 interactions
Concern with lithium and pregnancy
avoid in pregnancy
a/w with cardiac malformations in first trimester; avoid in breastfeeding
Lithium levels increase with ____
decreased salt intake, sodium loss (e.g. with ACEi/ARBs, thiazide diuretics)
NSAIDs - aspirin and sulindac are safer options
Lithium levels decrease with ____
increased salt intake, caffeine, and theophylline
Increased risk of serotonin syndrome if lithium is taken with ____
SSRIs, SNRIs, triptans, linezolid, and other serotonergic drugs
Increased risk of neurotoxicity (e.g. ataxia, tremors, nausea) if lithium is taken with ___
verapamil, diltiazem, phenytoin, and carbamazepine
___ lithium citrate syrup = ____ lithium ion
___ of lithium ion = ____ lithium carbonate tabs/caps
5mL lithium citrate syrup = 8 mEq lithium ion
8 mEq lithium ion = 300 mg lithium carbonate tabs/caps
During pregnancy, ____ is a safer option relative to other mood stabilizers (valproate, carbamazepine, lithium) for bipolar disorder. SGAs are also safer than valproate, carbamazepine, or lithium. ___ has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for bipolar depression.
Lamotrigine
Lurasidone
Concern with valproate in pregnant pts with bipolar disorder
increase risk of fetal anomalies, including neural tube defects, fetal valproate syndrome and long-tern adverse cognitive effects
avoid in pregnancy, esp during 1st trimester
Concern with carbamazepine in pregnant pts with bipolar disorder
fetal carbamazepine syndrome, which can result in facial abnormalities and other significant issues
avoid in pregnancy esp during 1st trimester
Concern with lithium in pregnant pts with bipolar disorder
can cause increase in congenital cardiac malformations and other abnormalities
