Bipolar Flashcards
Biological theories of BP
GABA deregulation
Increased noradrenergic activity
Voltage-gated ion channel problems
Electrical signal problems
BP stats
starts in early 20s
equal prevalence in men and women
1.2% of adults
BP history of illness
Symptoms get worse quickly, only a few days.
There’s often a stressor.
Mania can last days to months
Hypomania
Doesn’t cause major impairment
Rapid cycling
Having 4 or more mood episodes during the last 12 months
Doesn’t involve hypomania
Other than being rapid, the episodes are the same as non-rapid episodes
20% of BP patients have rapid cycling. 90% of rapid cyclers are women.
Antidepressants can increase the speed even more
Rapid cycling is a poor prognosis
Mania can be precipitated by
antidepressants
ECT
light therapy
Lithium (general info)
Works well for mania, and some effect for depressive symptoms
Therapeutic response takes 1 or 2 weeks
If the patient has rapid cycling, they won’t respond to Lithium monotherapy.
Lithium labs
thyroid
serum creatinine
BUN
Pregnancy
EKG if over 50 years old
Lithium side effects
Endocrine- weight gain, impaired thyroid
CNS- Fine hand tremors, coarse tremors when toxic, fatigue, mental cloudiness, headaches, nystagmus
Derm- Maculopapular rash, pruritus, acne
GI-cramps, anorexia, NVD
Renal- Polyuria with polydipsia, DI, edema, tubular changes
Cardiac- T wave inversions, dysrhythmias
Hema- Leukocytosis
Carbamazepine (general info)
BB warning for agranulocytosis and aplastic anemia
Baseline labs: CBC, LFTs,
Labs after 1 week of treatment: CBC, LFTs, 12 hour trough level
Therapeutic response takes 1 or 2 weeks
Valproic acid/divalproex sodium (general info)
BB warning for hepatotoxicity and pancreatitis
Baseline labs: CBC, LFTs,
Labs after 1 week of treatment: CBC, LFTs, 12 hour trough level
Therapeutic response takes 1 or 2 weeks
Lithium dose, side effects, comments
1200 to 2400mg (acute)
900 to 1200 mg (maintenance)
.8 to 1.2 (acute)
.6 to 1.2 (maintenance)
Side effects: Nausea, fine tremor, increased urination/thirst
Toxicity: coarse tremor, slurred speech, confusion, severe GI upset
Pregnancy D, L3. Especially avoid it during the 1st trimester.
Taking it with NSAIDs and ACE inhibitors doubles the level
Carbamazepine dose, side effects, comments
10 to 20 mg/kg/day
therapeutic level: 6 to 12
Side effects: Nausea, dizziness, sedation, headache, dry mouth, constipation, skin rash
Rare side effects: SJS (especially for Asians with the HLA-B 1502 allele), agranulocytosis, aplastic anemia
Monitor LFTs
Pregnancy D, L2
Valproic acid, divalproex dose, side effects, comments
15 to 40 mg/kg/day
Loading dose is 20 mg/kg/day
level: 50 to 125
Side effects: Nausea, diarrhea, cramps, sedation, tremor
Rare side effects: Elevated liver enzymes, SJS (unlike carbamazepine, it doesn’t have anything to do with the HLA-B allele)
Divalproex has less GI side effects.
These are better than lithium for rapid cycling and mixed episodes
Pregnancy D, L2
Lamotrigine
25 to 600 mg/day
Blood monitoring is not necessary
Side effects: Dizziness, ataxia, somnolence, diplopia, nausea, headache, hepatotoxicity
Rare side effects: SJS (doesn’t have anything to do with the HLA-B), leukopenia
It’s only indicated for maintenance therapy
It’s good for the depressive phase
Titrate slowly (increase every 2 weeks)
Using it with divalproex can double the concentration
Often used with Li, 2nd gens, and antidepressants
