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Year 3 - Clinical (Winter) > 7 - Bipolar Affective Disorder > Flashcards

7 - Bipolar Affective Disorder Flashcards

1
Q

Types of bipolar affective disorder

A
  • Bipolar 1 -> manic + major depression or mixed episode
  • Bipolar 2 -> hypomania + major depression
  • Cyclothymia -> fluctuations between subsyndromal depressive & hypomanic episodes; > 2 years of sx
  • Dysthymia -> chronic subsyndromal depressive episodes
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2
Q

Manic episode sx

A

FAST LANE

  • Flight of ideas
  • Activity increased (goal directed)
  • Sleep decreased (but feels rested)
  • Talk increased (pressure of speech)
  • Lability increased
  • Attention decreased (distractible)
  • Narcissistic increased (grandiose)
  • Excessive increased (hedonistic)
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3
Q

Compare and contrast manic vs. hypomanic vs. mixed

A

Manic
- > 1-week period
- Abnormal & persistently elevated mood
- At least 3 sx/ 4 if irritable
- Need for hospitalization – harm others/ self, psychosis
Hypomanic
- At least 4 days
- Abnormal & persistently elevated mood
- No need for hospitalization
Mixed
- Both major depressive and manic episodes
- > 1-week sx

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4
Q

What are rapid cyclers?

A
  • 4 or more episodes/year
  • Poor long-term prognosis
  • Multiple mood stabilizers
  • Risk factors = antidepressants, stimulant use, hypothyroidism, premenstrual period, postpartum period
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5
Q

Causes of acute mania

A
  • Seasonal change
  • Stressors
  • Sleep deprivation
  • Bright light
  • ECT
  • Antidepressants
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6
Q

Depressive sx

A

D SIG E CAPS

  • Depressive mood
  • Sleep decreased
  • Interest decreased (anhedonia)
  • Guilt/ worthlessness increased
  • Energy decreased
  • Concentration decreased
  • Appetite/ weight decreased
  • Psychomotor decreased
  • Suicide/ thoughts of death increased
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7
Q

Tx for goals for bipolar

A
  • Shorten episode
  • Decrease sx (response)
  • Restore function
  • Eliminate sx (remission)
  • Prevent relapse
  • Minimize adverse effects of tx
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8
Q

Therapeutic classes of drugs for bipolar

A
  • Mood stabilizers – lithium, valproate, carbamazepine, lamotrigine, gabapentin, topiramate, olanzapine, risperidone
  • Other agents for acute mania
    • Typical antipsychotics – haloperidol, chlorpromazine
    • BZDs
  • Other agents for acute depression
    • Antidepressants
    • ECT
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9
Q

Describe px who may not respond to lithium

A
  • Rapid cyclers
  • Mixed states
  • Comorbid conditions (ex: substance abuse)
  • Absence of episodic bipolar illness in family
  • Secondary mania
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10
Q

Advantages and disadvantages to anticonvulsants as mood stabilizers

A
  • Wider therapeutic range than lithium
  • Neurologic toxicity
  • Carbamazepine – hematologic
  • Lamotrigine – severe rash
  • Weight gain = valproic acid, carbamazepine; weight loss = topiramate
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11
Q

Role of atypical antipsychotics for BAD

A
  • Alternative first line agent to lithium or divalproex as monotherapy in acute mania or for maintenance therapy
  • Can be used in combination w/ lithium or divalproex
  • Second line agent as monotherapy for acute depression
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12
Q

Maintenance tx for BAD

A
  • No difference in olanzapine vs. divalproex for recurrence of affective episodes
  • Higher d/c rate for olanzapine likely b/c of metabolic side effects
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13
Q

Initial tx for BAD (non-pharms)

A
  • Assess for secondary causes of mania or mixed states (ex: alcohol or drug use)
  • D/c antidepressants
  • Taper off stimulants & caffeine if possible
  • Treat substance abuse
  • Encourage good nutrition (w/ regular protein & essential fatty acid intake), exercise, adequate sleep, stress reduction, & psychosocial therapy
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14
Q

Algorithm for tx of acute mania of BAD

A
  • 1st, 2 or 3 drug combinations – lithium, valproate, or SGA plus BZD and/or antipsychotic for short-term adjunctive tx of agitation or insomnia
  • Don’t combine antipsychotics
  • Alternative medication tx options = carbamazepine (oxcarbazepine if pt doesn’t respond or tolerate)
  • 2nd, if response if inadequate, consider 3 drug combination – lithium + anticonvulsant + antipsychotic OR anticonvulsant + anticonvulsant + antipsychotic
  • 3rd, if response is inadequate, consider ECT for mania w/ psychosis or catatonia, or add clozapine for tx refractory illness
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15
Q

Role of typical antipsychotics for BAD

A
  • Acute mania – haloperidol & chlorpromazine effective
  • May induce major depression
  • D/c once acute phase stabilized
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16
Q

Tx options for acute depression in BAD

A
  • Lithium, lamotrigine (first option = lithium; if already on lithium then add lamotrigine – this will likely stabilize mood, don’t need to go to antidepressant)
  • If severely ill – mood stabilizer + antidepressant (olanzapine + fluoxetine)
  • If currently on VPA – add lithium
17
Q

Tx options for severe depressive episode in BAD

A
  • 1st, optimize current mood stabilizer or initiate mood-stabilizing medication (lithium or quetiapine; alternative = fluoxetine/ olanzapine combination)
  • If psychosis present, initiate an antipsychotic in combination w/ above
  • Don’t combine antipsychotics
  • Alternative anticonvulsants = lamotrigine, valproate
  • 2nd, if response inadequate, consider carbamazepine or adding antidepressant
  • 3rd, if response inadequate, consider 3 drug combination (lithium + lamotrigine + antidepressant; lithium + quetiapine + antidepressant)
  • 4th, if response inadequate, consider ECT for tx-refractory illness & depression w/ psychosis or catatonia
18
Q

Tx duration for BAD

A
  • Sx resolution w/ mood stabilizers –> mania = 7 days; depression = 2-3 weeks, up to 6 weeks
  • Acute mania –> after remission, continue w/ mood stabilizers; after 2-6 months taper & d/c adjunctive meds; 1st episode d/c mood stabilizer after 1 year; lifelong tx for recurrent episodes, severe episodes, family hx, & rapid onset mania
  • Depression –> continue on mood stabilizer; antidepressant continue 6-12 weeks after remission then taper over 2-4 weeks (to prevent swing to mania)
19
Q

Describe the PK of lithium (therapeutic range, when to take sample, when to increase dose)

A
  • Lithium = gold standard for tx
  • Therapeutic concentration range
    • Acute = 0.8 – 1.2 mmol/L
    • Chronic = 0.6 – 1.2 mmol/L
  • 300 mg = 0.3 mmol/L
  • Take sample in morning before AM dose (12 h after last evening dose)
  • Rationale for OD dosing = decrease urine volume & compliance; can increase nausea
  • Acute mania increases clearance; increase dosage to maintain level but may need to decrease dose for chronic maintenance tx; monitor!!
20
Q

Lithium monitoring endpoints

A
  • Effectiveness
  • Adherence
  • Education
  • Dosage (volume status, renal status, serum concentrations)
    • Monitor every week until stable
  • Drug interactions
  • Toxic signs & sx
21
Q

Lithium – drug interactions

A
  • Increased concentrations –> NSAIDs, ACE inhibitors, ARBs, diuretics (fine to take Li w/ ACE/ARB, but anytime there is a change in ACE/ARB must change Li as well)
  • Decreased concentrations –> high sodium levels, theophylline, caffeine
  • Increased neurotoxicity –> antipsychotics, SSRIs, carbamazepine (if must use in combo w/ any of these, keep Li serum concentrations at lower end of normal)
22
Q

Lithium – dose related adverse effects

A
  • Initial = fine hand tremor, GI upset, muscle weakness
  • Moderate (1.5 – 2.5 mmol/L) = twitching, slurred speech, confusion
  • Severe (> 2.5 mmol/L) = seizures, stupor, coma, CV collapse
  • *Chronic toxicity may cause sx to be manifested at lower levels
23
Q

Lithium – chronic adverse effects

A
  • Neurological (tremor, impaired memory)
  • Renal (nephrogenic diabetes insipidus, nephrotoxicity)
  • CV (non-specific T wave changes)
  • Hypothyroidism
  • Weight gain
24
Q

Valproic acid – therapeutic range, SE, when to test levels, dosing

A
  • Dosed BID or TID; take same way each day
  • Therapeutic range not well established for mood disorder (50 – 125 mg/L, up to 150 mg/L)
  • SE – sedation, N/V, fine tremor, dizziness
  • Test levels at 2-4 days, then q5-7days until stable
25
Q

Lamotrigine - dosing, SE

A
  • Dosed once daily
  • Initial = 25 mg OD x 2 weeks, then 50 mg OD x 2 weeks, then 100 mg OD up to 200 mg OD or 100 mg BID
  • Most often used for px w/ bipolar depression, but still second or third line b/c of severe rash
    • Rash most often seen at 2-8 weeks, some > 6 months
  • Common SE = dizziness, headache, somnolence, nausea

Year 3 - Clinical (Winter) (30 decks)

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