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3153 Finals > Bipolar > Flashcards

Bipolar Flashcards

1
Q

State potential causes of Medication/substance induced mania (8)

A

1) Antidepressants (MAOIs, TCAs, 5 HT and/or NE
and/or DA reuptake inhibitors, 5 HT antagonists)

2) Steroids

3) Thyroid preparations (T3/T4)

4) Dopamine augmenting agents (CNS stimulants:
amphetamines, cocaine, sympathomimetics; DA
agonists, releasers, and reuptake inhibitors)

5) Norepinephrine augmenting agents (α2 antagonists, ß
agonists, NE reuptake inhibitors)

6) Alcohol

7) Drug withdrawal states (alcohol, α2 agonists,
antidepressants, barbiturates, benzodiazepines, opiates)

8) OTC weight loss agents and decongestants (ephedra, pseudoephedrine)

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2
Q

State potential medical conditions that may induce mania (2)

A

1) Cushing’s disease , hyperthyroidism (mania), hypothyroidism (depression)

2) CNS disorders (stroke, head injuries, multiple sclerosis)

Others: CNS infx, electrolyte abnormalities, vitamin/ nutritional deficiency.

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3
Q

State the DSM-5 criteria for manic episode

A

Signs and symptoms of mania for at least 1 week with functional impairment

Persistently Elevated/expansive mood + 3 Symptoms or 4 symptoms (DIGFAST) if mood is only irritable:

o Distractibility and easily frustrated

o Irresponsibility and erratic uninhibited behavior
- E.g Excessive involvement in activities that are pleasurable but have a high risk for serious consequences (buying sprees, sexual indiscretions, poor judgment in business ventures

o Grandiosity
- Inflated self-esteem -> opposite of thoughts people get in depression

o Flight of ideas
- “Racing of thoughts” -> appears like psychosis

o Activity increased
- ↑ goal directed activities or psychomotor agitation

o Sleep:
- Need is decreased (e.g. feels rested after only 3 hrs of sleep)

o Talkativeness
- More talkative than usual -> rambling monologue, no time to cut in; pressured speech

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4
Q

Describe what is meant by Bipolar I and Bipolar II

A
  • Bipolar I = Mania ± Depressive episodes
  • Bipolar II = Hypomania + Depressive episodes
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5
Q

State the DSM criteria for hypomania

A
  • Hypomanic: Sx ≥ 4 days (No functional impairment, No psychosis)
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6
Q

State the goals of treatment of Bipolar (3)

A

1) Reduce frequency, severity and duration of mood episodes
2) Prevent suicide
3) Avoid stressors or substances that may trigger

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7
Q

State some non-pharmacological measures for Bipolar (4)

A
  • Psychotherapy (e.g., individual, group, and family), interpersonal therapy, cognitive behavioral therapy (or iCBT), behavioral couples therapy
  • Stress reduction techniques, relaxation therapy,
  • Sleep Hygiene (regular bedtime and awake schedule; avoid alcohol or caffeine intake prior to bedtime)
  • Recognise early signs and symptoms of mania and depression (keep mood diary)
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8
Q

State the clinically significant DDIs that increase risk of Li toxicity

A

Sodium depletion
Thiazides
ACE inhibitors/ ARBs
NSAIDs
Dehydration

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9
Q

State ADRs of Li (9)

A

1) Fine to coarse tremors
2) Polyuria
3) Hypothyroidism
4) Cardiac effects (ECG changes)
5) Nausea
6) Weight gain
7) Fatigue
8) Cognitive impairment
9) Diabetes insipidus

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10
Q

State the plasma concentration at which Li toxicity starts to occur

A

1.5-2 mEq/L

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11
Q

State a side effect of severe Li toxicity

A

Coma

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12
Q

Which drug can be used to treat bipolar depression but not bipolar mania (no anti-manic effects)?

A

Lamotrigine

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13
Q

Which drug can be used to treat mania but not bipolar depression (no anti-depressant effects)?

A

Haloperidol

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14
Q

State the first line MAINTENANCE treatment of either bipolar depression or mania

A

Lithium

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15
Q

Which SGA has limited antidepressant effect and is hence used in combination with Fluoxetine to treat bipolar despression?

A

Olanzapine

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16
Q

What is the target range of Sodium Valproate?

A

50-125mcg/mL (steady state in 3-5 days)

17
Q

What are the ADRs of Sodium Valproate? (4)

A

1) Thrombocytopenia
2) Pancreatitis
3) Increased weight
4) SJS/TEN

18
Q

What is the target range of Carbamazepine?

A

4-12mcg/mL in 4 wks

19
Q

ADR of carbamazepine (2)

A

Agranulocytosis
SLE/TEN

20
Q

State the role of Benzodiazepines in treatment of Bipolar

A
  • Given short course and as PRN to help patient relax and sleep
  • Taper off when condition improved & mood stabilizer optimized.
21
Q

Which drug for bipolar is not hepatically cleared?

A

Lithium

22
Q

State potential Bipolar tx options (incl non-pharm) for Pregnant patients and things to take note (4)

A
  • Avoid all medications for 1st trimester
  • Avoid Valproate
  • Can consider SGA
  • Consider ECT for severe mania, mixed episode, depression or psychosis
23
Q

State when switching/ adding on therapies is indicated and what is normally done. State what is last line

A

When no/ inadequate response within 2-4 weeks.

Usually add on second first line agent (for partial response) or switch to SGA (if no response)

CBZ reserved as last line

24
Q

State when ECT may be indicated and things to note before it is conducted

A

Severe or treatment resistant mania/depression

Omit Lithium, Anticonvulsants and Benzodiazepines (at least 12hrs) just before ECT, except when Lorazepam/Clonazepam is used for catatonia

25
Q

State what drugs are to be avoided in rapid cycling

A

Avoid antidepressants/ stimulants (applies to history of antidepressant induced mania)

26
Q

State the monitoring parameters for Lithium treatment (8)

A

FBC, Renal panel, Thyroid fn tests, Electrolytes (serum Na and Ca to monitor for HyperCa, sodium depletion), Metabolic (BMI, Lipids, FBG), Serum Li, Pregnancy test, ECG (for those >40y.o or got Cardiac Disease)

27
Q

Which bipolar drug is the most effective in decreasing suicide risk?

A

Lithium

28
Q

State how you would counsel a patient starting on bipolar medication (incl purpose of meds, important things to note, administration instructions, non-pharm)

A

o “This is a mood stabilizing medication, to allow you to have better control and do not get carried away by your emotions”

o “It may cause drowsiness. (and best taken at night/bed time) -> take after dinner if morning wake up but still tired

o “See Dr immediately if you experience any severe and bothersome side effects such as rashes, tremors, nausea, fever or sore throat, or if feeling suicidal or unwell.”

o Some other non-pharmacological ways that may help you with your problems would be keeping a mood diary to identify what triggers your mood episodes so that you can try to avoid. Try relief stress/ relaxation techniques. Try to have proper sleep hygiene. Consider seeing a therapist.

o Avoid taking this medication with alcohol. Space them 4-6 hours apart

o Inform your doctor if you planning to have a baby (for females on VPA)

29
Q

1st episode presentation of bipolar in males is usually a ____ episode while for females is ____ episode

A

Manic, Depressive

30
Q

State DOC in maintenance phase of bipolar depression, for person not suitable for Lithium but want something with less sedation and weight gain

A

Lamotrigine

31
Q

State the drugs for bipolar that require TDM

A

Li, Valproate, CBZ

32
Q

State the drugs for bipolar that do not require TDM

A

SGA, Lamotrigine

33
Q

Which population is Valproate use not recommended in?

A

Women with childbearing potential

34
Q

State at which times TDM is done for Li, CBZ and Valproate

A

1) Li: Samples drawn 12 hr after last dose. Done 5-7 days after initiation, titration or when new interacting drugs added

2) CBZ: Trough sample needed (take before administering 1st dose of the day). Steady state only after 2-4 weeks

3) Valproate: Trough sample needed (take before administering 1st dose of the day). Done 2-3 days after starting or titrating

35
Q

State the first line therapy for ACUTE mania

A

SGAs (Olanzapine, Risperidone, Quetiapine, Aripiprazole, Haloperidol)

Olanzapine most commonly used, Risperidone good for severe mania, Haloperidol watch out for EPSE + no anti-depressant properties, Quetiapine slow titrate due to orthostatic hypotension

36
Q

State first line for ACUTE bipolar depression

A

SGAs (Olanzapine + Fluoxetine, Quetiapine)

3153 Finals (8 decks)

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