Bipolar Flashcards
State potential causes of Medication/substance induced mania (8)
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)
State potential medical conditions that may induce mania (2)
1) Cushing’s disease , hyperthyroidism (mania), hypothyroidism (depression)
2) CNS disorders (stroke, head injuries, multiple sclerosis)
Others: CNS infx, electrolyte abnormalities, vitamin/ nutritional deficiency.
State the DSM-5 criteria for manic episode
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
Describe what is meant by Bipolar I and Bipolar II
- Bipolar I = Mania ± Depressive episodes
- Bipolar II = Hypomania + Depressive episodes
State the DSM criteria for hypomania
- Hypomanic: Sx ≥ 4 days (No functional impairment, No psychosis)
State the goals of treatment of Bipolar (3)
1) Reduce frequency, severity and duration of mood episodes
2) Prevent suicide
3) Avoid stressors or substances that may trigger
State some non-pharmacological measures for Bipolar (4)
- 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)
State the clinically significant DDIs that increase risk of Li toxicity
Sodium depletion
Thiazides
ACE inhibitors/ ARBs
NSAIDs
Dehydration
State ADRs of Li (9)
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
State the plasma concentration at which Li toxicity starts to occur
1.5-2 mEq/L
State a side effect of severe Li toxicity
Coma
Which drug can be used to treat bipolar depression but not bipolar mania (no anti-manic effects)?
Lamotrigine
Which drug can be used to treat mania but not bipolar depression (no anti-depressant effects)?
Haloperidol
State the first line MAINTENANCE treatment of either bipolar depression or mania
Lithium
Which SGA has limited antidepressant effect and is hence used in combination with Fluoxetine to treat bipolar despression?
Olanzapine
What is the target range of Sodium Valproate?
50-125mcg/mL (steady state in 3-5 days)
What are the ADRs of Sodium Valproate? (4)
1) Thrombocytopenia
2) Pancreatitis
3) Increased weight
4) SJS/TEN
What is the target range of Carbamazepine?
4-12mcg/mL in 4 wks
ADR of carbamazepine (2)
Agranulocytosis
SLE/TEN
State the role of Benzodiazepines in treatment of Bipolar
- Given short course and as PRN to help patient relax and sleep
- Taper off when condition improved & mood stabilizer optimized.
Which drug for bipolar is not hepatically cleared?
Lithium
State potential Bipolar tx options (incl non-pharm) for Pregnant patients and things to take note (4)
- Avoid all medications for 1st trimester
- Avoid Valproate
- Can consider SGA
- Consider ECT for severe mania, mixed episode, depression or psychosis
State when switching/ adding on therapies is indicated and what is normally done. State what is last line
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
State when ECT may be indicated and things to note before it is conducted
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
State what drugs are to be avoided in rapid cycling
Avoid antidepressants/ stimulants (applies to history of antidepressant induced mania)
State the monitoring parameters for Lithium treatment (8)
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)
Which bipolar drug is the most effective in decreasing suicide risk?
Lithium
State how you would counsel a patient starting on bipolar medication (incl purpose of meds, important things to note, administration instructions, non-pharm)
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)
1st episode presentation of bipolar in males is usually a ____ episode while for females is ____ episode
Manic, Depressive
State DOC in maintenance phase of bipolar depression, for person not suitable for Lithium but want something with less sedation and weight gain
Lamotrigine
State the drugs for bipolar that require TDM
Li, Valproate, CBZ
State the drugs for bipolar that do not require TDM
SGA, Lamotrigine
Which population is Valproate use not recommended in?
Women with childbearing potential
State at which times TDM is done for Li, CBZ and Valproate
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
State the first line therapy for ACUTE mania
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
State first line for ACUTE bipolar depression
SGAs (Olanzapine + Fluoxetine, Quetiapine)
