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Therapeutics 2 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

Which disorder is more common in women?

A

Bipolar II

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2
Q

Mean age of onset of bipolar disorder

A

20, but it can happen anytime between early childhood and the mid-40’s

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3
Q

Etiology of bipolar disorder

A

exact etiology is unknown
thought to be genetically based
influenced by a variety of factors including trauma, environmental factors, anatomical abnormalities, exposure to chemicals or drugs, and others

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4
Q

Characteristics of bipolar I disorder

A

At least one episode of mania for at least one week or longer with persistently elevated, expansive, or irritable mood and related symptoms of decreased need for sleep, excessive energy racing thoughts, a propensity for high-risk activities, and excessive talkativeness
Depression may be misdiabnosed as MDD. It is important to rule out previous episodes of mania before treating.

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5
Q

What happens if a bipolar patient is treated only for depression?

A

Can precipitate mania or cause rapid fluctuations between mania and depression

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6
Q

Characteristics of bipolar II disorder

A

Distinguishing feature is depression with past hypomanic episodes, often not recalled by individual as being unusual
irritability and anger are also common
there cannot have been a prior full manic episode.

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7
Q

Criteria for a manic episode

A

Abnormal and persistent elevated mood for 1 week or more, associated with at least 3 of the following:
Inflated self-esteem
Racing thoughts
Distractible/poor attention
Increased activity or increased motor activity or agitation
excessive involvement in activities that are pleasurable but have high risk for serious consequences

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8
Q

Criteria for a hypomanic episode

A

At least 4 days of abnormal and persistent elevated mood associated with at least 3 of the following:
Inflated self-esteem
decreased need for sleep
increased talking
racing thoughts
increased activity or increased motor activity or agitation
excessive involvement in activities that are pleasurable but have a high risk for serious consequences

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9
Q

Criteria for a mixed episode

A

Meets the criteria for both a major depressive episode and a manic episode, and occurs nearly daily for at least a 1 week period

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10
Q

Psychiatric comorbidities with bipolar disorder

A

personality disorders
alcohol and substance abuse or dependence
anxiety disorders (panic disorder, OCD, social phobia, eating disorders)
ADHD

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11
Q

Medical comorbidities with bipolar disorder

A 
migraine
MS
Cushing's syndrome
Brain tumor
Head trauma
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12
Q

Medications that can cause, contribute, or exacerbate mania

A 
Corticosteroids
Diltiazem
Levodopa
Oral Contraceptives
Zudovudine
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13
Q

Illicit substances that can cause, contribute, or exacerbate mania

A

Anabolic steroids
Hallucinogens
Stimulants (cocaine and amphetamine)

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14
Q

nonpharmacologic therapy for patients with bipolar disorder

A

interpersonal, family, or group therapy
cognitive behavioral therapy
electroconvulsive therapy
psychoeducation for patients and family

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15
Q

When is lithium considered most effective?

A

In patients with few previous episodes, symptom-free inter-episode remission, and family history of bipolar disorder with good response to lithium

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16
Q

Starting dose of Lithium

A

600-900mg/day in 2-4 doses

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17
Q

Desired serum lithium concentration

A

0.6-1.1mEq/L for maintenance

1-1.5mEq/L for acute treatment

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18
Q

Symptoms of Lithium toxicity

A

Occurs at concentrations >2mEq/L
Severe vomiting and diarrhea
Deterioration in motor coordination (coarse tremor, ataxia, dysarthria)
Impaired cognition
More severe - Seizure, cardiac arrhythmia, Coma, and kidney damage

19
Q

How is lithium metabolized?

A

it isn’t! only excreted through the kidneys

20
Q

Divalproex is used best in what kinds of patients?

A

Patients with rapid cycling, mixed mood features, and substance abuse comorbidity

21
Q

Divalproex Mechanism

A

Not well understood
Affects ion transport and enhances GABA activity
Possible neuroprotective effects through enhancement of BDNF

22
Q

Usual starting dose of Divalproex

A

500-1000 mg/day

23
Q

Desired serum VPA concentration

A

50-125 mcg/mL

It is not unusual for patients to require >100 mcg/mL for optimal efficacy

24
Q

Interaction between VPA and lamptrigine

A

Risk of dangerous rash

25
Q

Starting dose of Carbamazepine

A

400-600 mg/day

26
Q

Desired serum carbamazepine concentration

A

4-12 mcg/mL

27
Q

Lamotrigine is more effective for…

A

Depression relapse prevention over mania relapse

28
Q

Usual starting dose of lamotrigine (without being added to divalproex)

A

25mg/day for the first 1-2 weeks, then double dose every 1-2 weeks to a target of 100-400 mg/day

29
Q

Lamotrigine adverse effect

A

Maculopapular rash which can progress to life-threatening SJS is most significant.
GI upset, tremor, polyuria, polydipsia, hypothyroidism, poor concentration, alopecia, worsening of psoriasis, weight gain, metallic taste, benign reversible leukocytosis
Less common - can cause and/or worsen cardiac arrhythmias

30
Q

Advantages of oxcarbazepine over carbamazepine

A

Don’t need to monitor routinely, less likely to cause hematologic abnormalities
Less significant drug interactions

31
Q

Oxcarbazepine adverse effects

A

drowsiness
dizziness
GI upset
hyponatremia

32
Q

Bipolar disorder and drugs during pregnancy

A

Need to weigh the risks of teratogenicity of the drugs with the risk of bipolar relapse in the mother without treatment and potential consequent harm to both mother and fetus

33
Q

Lithium and pregnancy

A

May cause Ebstein’s anomaly during first trimester
Downward placement of tricuspid valve into right ventricle.
Maternal renal clearance increases, which requires dose increases to maintain desired serum concentrations
Can also cause hypotonicity and cyanosis in neonates (floppy baby syndrome)
Readily transferred in breast milk, do not breast feed

34
Q

VPA and pregnancy

A

neural tube defects (spina bifica), and risk of facial abnormalities is increased

35
Q

Carbamazepine and pregnancy

A

neural tube defects

Can cause fetal vitamin K deficiency (facial abnormalities and clotting/bleeding problems)

36
Q

VPA adverse effects

A

GI (loss of appetite, nausea, dyzpepsia, diarrhea), tremor, drowsiness, weight cain
Less common - alopecia, polycystic ovarian syndrome, thrombocytopenia
Even more rare - hepatic toxicity and pancreatitis

37
Q

Carbamazepine adverse effects

A

drowsiness, dizziness, ataxia, lethargy, confusion, diplopia, dysarthria, GI upset
Rare - aplastic anemia, agranulocytosis. Both are life-threatening

38
Q

Lithium drug interactions

A

Thiazide diuretics, NSAIDs, ACEIs

39
Q

VPA drug interactions

A

Other anticonvulsants, TCAs, and lamotrigine

40
Q

Carbanazepine drug interactions

A

Increased metabolism of: Other anticonvulsants, antipsychotics, some antidepressants, OCs, antiretrovirals
The following inhibit carbamazepine metabolism: antidepressants, macrolide antibiotics, azole antifungles, and grape fruit juice
Clozapine increases risk of agranulocytosis
Carbamazepine is an autoinducer!

41
Q

Lithium monitoring parameters

A

baseline: pregnancy test, ECG if >40y or has cardiac disease, CBC, glucose, lipids, weight, renal function, thyroid function, electrolytes, and dermatologic tests
Routine q6-12 months: Lithium level, weight, CBC, Renal function, thyroid function, electrolytes, and dermatologic tests

42
Q

VPA monitoring parameters

A

baseline: pregnancy test, hepatic function, derm tests
Routine: serum concentrations every 2 weeks until stable, then as infrequently as twice yearly. Weight, liver function, and derm tests

43
Q

Carbamazepine monitoring parameters

A

Baseline: Blood tests and serum concentration, liver function, renal function, serum electrolytes, and derm tests
Routine:blood tests and serum concentrations, liver function, serum electrolytes, and derm tests

Therapeutics 2 (11 decks)

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