70 - Bipolar Flashcards
clinical factors
disease course
- onset late adolescence/early adulthood
- episodes lasting a few weeks to several months
- acceleration of cycle frequency common as illness progresses
- ___ is the mood pole that is experienced most often in bipolar disorder - can lead to misdiagnosis
comorbidities
- ___ and ___ use common
- 2-3x higher mortality rate than general population
- ___ disorders can significantly impact remission of modd episodes if left untreated or inadequately treated
- depression
- alcohol, substance
- anxiety
definitions
mania - abnormally and persistently elevated, expansive, or irritable mood
- grandiosity, flight of ideas, distractibility, decreased need for sleep, excessive pleasurable activities
- hospitalization generally required, may involve psychosis
- change in ___ pattern often initiates an episode
hypomania - less severe form of mania
- hospitalization NOT often required
- elevated, expansive, or irritable mood
- inflated self esteem, decreased need for sleep, distractibility
- no ___ features
rapid-cycling - characterized by __ or more mood episodes in 1 year
- sleep
- psychotic
- 4
bipolar disorder classification
Bipolar I diorder: greater than __ or more manic episodes
- depressive or hypomanic episode may have occurred
- manic episodes generally last __ week or greater
Bipolar II disorder: major depressive and ___ episodes
- episodes generally last __ days or longer
1
1
hypomanic
4
BPD with mixed features
mixed features specifier can apply to manic, hypomanic, or depressive episodes in bipolar I or II
manic/hypomanic episode with mixed features (include __ or more)
- dysphoria/depressed mood
- diminished ___ or pleasure in activities.
- psychomotor ___
- fatigue or loss of energy
- feeling or worthlessnes or guilt
- recurrent thoughts of ___
depressive episode with mixed feautures (include __ or more)
- elevated, expansive mood
- inflated self-esteem or grandiosity
- more talkative than usual or pressure to keep talking
- flight ideas or racing thoughts
- ___ involvement of activities with high potential for consequences
- ___ energy/goal-directed activities
- ___ need for sleep
- 3
- interest
- retardation
- death
- 3
- increased
- increased
- decreased
PCOL overview
___ are the foundation of acute and maintenance treatment
- 1st line: usually ___ or ___
- ___ antipsychotics can also be used 1st line as monotherapy or in combination with the ones above
- many patient will take polytherapy with mood stabilizers
mood stabilizers
- Li, valproic acid
- atypical
Li - Use and Dosing
decrease ___ and ___ of episodes in BPD
associated with ___ in suicidality
- has ___ - evaluate is pt has a suicidal plan, and if so, does it involce overdose via pill ingestion
dosing - 300-450 mg BID, usual maintenance dose ~900 mg/day
dosage forms
- citrate liquid (IR) and carbonate tablets/capsules (IR or CR)
- some diferrence in Li content, but use ___ : ___ conversion
- IR associated with increased ___ and ___
- CR associated with increased ___
- number, severity
- decrease
- NTI
- 1:1
- N/V
- diarrhea
Li - monitoring and AE
NTI
- acute treatment: 0.9-1.2 mEq/L
- maintenance: 0.6-0.9 mEq/L
- ___ (mild to severe): 1.5- > 3.0 mEq/L
toxicities
- GI, ataxia, coarse hand tremor, altered mental status, seizure, lethargy, confusion, agitation
SE
- fine hand ___ , ___ , polyuria, polydipsia, acne, dry mouth, weight gain, ECG changes
teratogenic
- cardiac structural abnormality (___’s anomaly)
- avoid in ___ trimester - use with caution in other trimesters
- toxicity
- tremor, hypothyroidism
- 1st
- Ebstein’s
Li - lab monitoring
- SCr, BUN (almost entirely ___ excreted)
- urine sepcific gravity
- electrolytes: ___ , ___ , and ___
- ___ (especially if age > 40 ir cardiac risk factors)
- thyroid function - ___ and ___
- parathyroid hormone
- CBC with differential
- weight
- pregnancy test
- renally
- Na, K, Ca
- ECG
- TSH, T4
Li - drug interactions
- decreased Li renal clearance ( ___ Li levels) - ___ , ARBs, ___ diuretics, ___ , dehydration
- increased Li renal clearance ( ___ Li levels) - caffeine, ___ diuretics, kinda ___ diuretics
- increased Li excretion ( ___ Li levels_ - sodium bicarbonate, high ___ intake
- toxicity related to ___ depletion - ___ diuretics
these drugs are not CI, just be aware
- increased, ACEi, thiazides, NSAIDs
- decreased, osmotic, loop
- decreased, Na
- Na, thiazide
valproate (valproic acid, divalproex)
available in several dosage forms risk for med errors
- ER is 10-15% ___ bioavailable than DR
- __ : __ conversion, expect lower serum [ ] with the ___ dosage form - usually not clinically significant
- changing IR to ER ___ the dose by 8-20%
- valproic acid syrup (IR) and capsule sprinkle form - higher risk for GI ___ (usually esophageal)
usual initial dose is 1000 mg given as a nighttime dose or split into 2 divided doses
- targeted dose: 1500-2000 mg daily as nighttime dose or split into 2 divided doses
- serum levels ___ - ___ mcg/mL associated with most efficacy in mania, obtain levels at least ___ days (96 hours) afterfirst dose or dose increase
- less
- 1:1, ER
- increased
- ulcers
- 80-125
- 4 days
valproic acid - AE
unsafe in ___ trimester of pregnancy
- obtain baseline pregnancy test
- often avoided in women of child-bearing age (use contraception if prescribed)
___ ___ syndrome occurs in up to 50% of women
- assess for menstrual cycle chages or hirsutism
- may treat with ___
- refer to endo
- any
- polycystic
- metformin
valproic acid - AE (cont)
- GI - ___ , N/V/D, dyspepsia, ___
- tremor, sedation, ataxia
- alopecia
- ___ , platelet dysfunction
- teratogenic - ___ tube defects, endurng negative effects in ___ of offspring
- elevated LFTs (usually asymptomatic)
- increased ___ - weight ___ (6-8 kg)
- rash
- Black box warning for hepatic failure (rare), pancreatitis
- hyper ___ - related to carnitine deficiency induced by valproate in some individuals, increased AMS
- anorexia, ulceration
- thrombocytopenia
- neural, IQ
- appetite, gain
- ammonemia
valproate - lab monitoring
- baseline - ___ test, ___ s, CBC w/differential
- routine - LFTs, CBC w/differential, platelets, serum concentration
- serum ammonia - if suspect hyper ___ (dont have to do routinely)
- pregnancy, LFTs
- hyperammonemia
valproate - DI
- many
- significany concern with combination use with ___ - increased ___ serum concentrations, increased risk of ___
- significantly reduced VPA level when given with ___
- lamotrigine, lamotrigine, Stevens-Johnson syndome
- ritonavir
other mood stabilizers
___ (Tegretol)
- 2nd or 3rd line
- known teratogen
- induce nearly all CYPs ( ___ of metabolism - steady state at 14 days)
- associated with ___ / hematologic effects
carbamazepine
- auto-induction
- thrombocytopenia
other mood stabilizers
___ (Lamictal)
- 1st line treatment for ___ symptoms in bipolar disorder
- NOT useful for acute treatment or for ___ episodes
- slow dose-titration due to risk for ___ syndrome
- retitrate if non-adherence for about ___ - ___ days or longer
- counsel patient to stop immediately if ___ occurs
- MUST know dose titration and dosing schedule - see seizure lecture notes/drug table
lamotrigine
- depressive
- manic
- Stevens-Johnson
- 3-5 days
- rash
