Bipolar

Question 1

Treatment for acute mania

Answer 1

Antipsychotic (olanzapine, quetiapiene, risperidone)

Question 2

Propylaxis for Bipolar?

Answer 2

Lithium (first line)

Sodium valproate (in combo with lithium or on its own if lithium not tolerated)

Carbamazepine (if unresponsive to lithium)

Question 3

What is the therapeutic range for lithium? (maintenance and acute episode levels?)

Answer 3

Maintenance: 0.4-1mmol/L
Acute episodes: 0/8mmol/L

Question 4

When should lithium levels be taken after a dose?

Answer 4

12 hours

Question 5

How often should lithium levels be monitored?

Answer 5

Every week after initiation
Every 3 months for 1 year
Every 6 months*

*remain every 3 months if high risk: over 65s, taking interacting dugs, renal or thyroid impairment, raised calcium, poor symptom control or adherence, if last lithium conc was 0.8mmol

Question 6

What other monitoring requirements are there for lithium?

Answer 6

Before initiation: Renal, cardiac, thyroid function, weight/BMI, electrolytes, FBC, calcium

Every 6 months: Weight/BMI, electrolytes, eGFR, thyroid, calcium

Question 7

Lithium signs of toxicity

Answer 7

Polyuria, incontinence
Tremors
Blurred vision
Confusion, restlessness, difficulty speaking, seizures
Diarrhoea and vomitting

Question 8

Interactions with lithium

Answer 8

Diuretics, Carbamazepine, SSRIs, Metronidazole
= Hyponatraemia

SSRIs, Tramadol
= Serotonin syndrome

Antiemetics, Antipsychotics
= Extrapyramidal s/e

RL-CCBs, Macrolides
= QT prolongation

NSAIDs, ACE-I, Metformin
= Increased toxicity

Tramadol
= Reduced seizure threshold

Amiodarone
= Ventricular arrythmias

Methyldopa, phenytoin, RL-CCBs
= neurotoxicity

Question 9

What is long term use of lithium associated with?

Answer 9

Thyroid issues and mild cognitive impairment

Question 10

How long should lithium be gradually reduced over and why should it not be stopped abruptly?

Answer 10

Increased risk of relapse

Reduce gradually over at least 4 weeks (ideally over 3 months)

Question 11

Is lithium brand specific?

Answer 11

Yes - varying bioavailability

Question 12

When should antidepressants NOT be used?

Answer 12

Avoided in;
- patients with rapid-cycling bipolar disorder
- a recent history of mania or hypomania
- or with rapid mood fluctuations

Question 13

Contraindications of lithium

Answer 13

CONTRAINDICATIONS
o Dehydration
o Decreased sodium
o Addison’s disease
o Hypothyroidism