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neurology/psychiatry > Bipolar > Flashcards

Bipolar Flashcards

1
Q

___% of patients with bipolar disorder have a relative with a mood disorder

A

80-90%

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2
Q

bipolar 1

A

criteria have been met for at least one manic episode

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3
Q

bipolar 2

A

criteria have been met for at least one hypomanic episode & at least one major depressive episode

THERE HAS NEVER BEEN A MANIC EPISODE

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4
Q

diagnosis can switch from ___ to ____

A

bipolar 2 to bipolar 1

(never the other way around)

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5
Q

criteria for a manic episode

A

abnormally & persistently elevated, expansive, or irritable mood with INCREASED GOAL-DIRECTED ACTIVITY/ENERGY lasting AT LEAST 1 WEEK and present most of the day, nearly every day. is sufficiently severe to cause impairment in functioning

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6
Q

during a manic period, 3 of the following symptoms are present

A

grandiosity
decreased sleep
pressured speech
racing thoughts
distracted
increased activity or psychomotor agitation
involvement in activities with serious consequences

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7
Q

mnemonic for manic episode

A

DIG FAST
Distractible
Impulsive
Grandiosity
Flight of ideas
Activities dangerous or hypersexual
Sleep decreased
Talkative

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8
Q

criteria for a hypomanic episode

A

lasting at least 4 DAYS, not severe enough to impair functioning or necessitate hospitalization
but otherwise basically the same as manic criteria

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9
Q

main difference between mania and hypomania

A

mania is for at least one week & severe enough to cause impairment in social/occupational functioning

hypomania is for 4 days and does not cause impairment in social/occupational functioning

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10
Q

criteria for a depressive episode

A

5 symptoms (depression symptoms) have been present during a 2 week period, at least one of the symptoms is depressed mood or loss of interest, and the symptoms cause clinically significant impairment

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11
Q

_________ is not required for a diagnosis of bipolar 1 disorder

A

major depressive episode

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12
Q

goal of bipolar treatment

A

restore euthymic mood

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13
Q

goals of acute phase

A

rapidly control behavioral symptoms, restore sleep, stabilize mood, reduce harm to self and others

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14
Q

goals of continuation phase

A

therapy continues x2-4 months during high risk of relapse, prevent relapse & optimize medications

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15
Q

goals of maintenance phase

A

after mood stability x 3 months, improve QOL, minimize number of effective agents, provide prophylaxis for future episodes
LIFETIME TREATMENT

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16
Q

2 categories of pharmacotherapy for bipolar

A

mood stabilizers
antipsychotics

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17
Q

4 mood stabilizers used for bipolar

A

lithium
lamotrigine
divalproex
carbamazepine

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18
Q

indication for lithium

A

bipolar maintenance with SUICIDALITY BENEFIT
manic, depressive, mixed episodes

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19
Q

lithium place in therapy

A

first line monotherapy & combo therapy for maintenance & acute manic, hypomanic, depressive, mixed episodes

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20
Q

lithium onset

A

7-14 days for mania
6-8 weeks for depression

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21
Q

300 mg of oral formulations of lithium= ___ mEq of Li

A

8.12

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22
Q

how is lithium eliminated

A

renally

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23
Q

boxed warning for lithium

A

toxicity is closely related to serum Li concentrations
can occur at doses close to therapeutic concentrations
prior to initiation, ensure access to TDM

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24
Q

each 300 mg increase in lithium dose results in ___ increase in level

A

0.3 mEq/L

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25
Q

therapeutic range of lithium for maintenance

A

0.6-1.2

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26
Q

therapeutic range of lithium for acute mania

A

1-1.2

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27
Q

n/v/d, polydipsia, muscle weakness, fine hand tremor occur at what range of lithium

A

1.2-1.5

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28
Q

coarse hand tremor, slurred speech, confusion occur at what range of lithium

A

1.5-2.5

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29
Q

stupor, seizure, hypotension, coma, death occur at what range of lithium

A

> 2.5

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30
Q

when to monitor lithium concentrations

A

after steady state (5 days)
obtain 12-hour levels (trough)

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31
Q

baseline monitoring for lithium

A

renal panel (BUN, SCr, lytes)
thyroid
pregnancy test
ECG for patients >40 or underlying risks

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32
Q

how often to monitor lithium levels

A

5-7 days after dose adjustments
then for 1 month
then every 6 months

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33
Q

how often to monitor renal & thyroid function for Lithium

A

every 6-12 months

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34
Q

how to take lithium

A

with food
at bedtime

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35
Q

how to mitigate GI side effects with lithium

A

take with food

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36
Q

how to mitigate tremor/fatigue with lithium

A

HS dosing, give CR, propranolol

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37
Q

how to mitigate polyuria & polydipsia with lithium

A

HS dosing & avoid caffeine

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38
Q

other side effects with lithium

A

weight gain (diet & exercise)
dermatologic (topical tx)
leukocytosis (benign)
hypothyroidism (supplement)
diabetes insipidus

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39
Q

MILD toxicity lithium

A

hand tremor, GI, fatigue

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40
Q

MODERATE toxicity lithium

A

coarse hand tremor, confusion, slurred speech, unsteady gait

41
Q

SEVERE toxicity lithium

A

seizures, stupor, coma, arrhythmia

42
Q

how to prevent lithium toxicity

A

consistent hydration & salt intake

43
Q

how to manage mild lithium toxicity

A

hold lithium, obtain level, educate patient

44
Q

how to manage severe lithium toxicity

A

hydrate, protect airway, hemodialysis, vitals, BUN, SCr, urinalysis, CBC w/ diff, ECG

45
Q

drugs that INCREASE lithium levels

A

NSAIDs
thiazides
ACEi/ARB

46
Q

drugs that DECREASE lithium levels

A

theophylline, spironolactone, caffeine

47
Q

indications for divalproex

A

bipolar mania, maintenance therapy

48
Q

place in therapy of divalproex

A

first line monotherapy & combo therapy for manic, hypomanic, & mixed episodes
* preferred agent for mixed episodes, may be beneficial in rapid cycling

49
Q

dosing considerations for divalproex

A

can be weight based or fixed dose (ex start at 25 mg/kg/day or 500-1000 mg HS)

50
Q

timing of monitoring for divalproex

A

trough levels after steady state (3-5 days)
18-24 hours post dose for once daily form
12 hours post dose for twice daily form

51
Q

therapeutic range for divalproex

A

50-125 mg/L

52
Q

effects seen at 75-100 mg/L divalproex

A

ataxia, sedation, lethargy, fatigue

53
Q

effects seen at 100-175 mg/L divalproex

A

tremor

54
Q

effects seen >175 mg/L divalproex

A

stupor, coma

55
Q

boxed warnings for divalproex

A

hepatotoxicity (first 6 months, may be fatal)
fetal risk
pancreatitis

56
Q

divalproex contraindications

A

hepatic disease, urea cycle disorders

57
Q

common side effects divalproex

A

n/v, weight gain, alopecia, sedation, tremor, fatigue

58
Q

serious side effects divalproex

A

hepatic failure, thrombocytopenia, pancreatitis, hyperammonemia

59
Q

baseline monitoring divalproex

A

CBC w/ platelets, LFTs, pregnancy test

60
Q

when to monitor valproate level

A

3-5 days after dose adjustments, valproate level every 6-12 months

61
Q

ongoing monitoring for divalproex

A

CBC & LFTs q6-12 months
NH3 if symptomatic or suspicion

62
Q

drugs that INCREASE divalproex levels

A

aspirin, warfarin, risperidone, fluoxetine

63
Q

drugs that DECREASE divalproex levels

A

carbamazepine, carbapenems, rifampin

64
Q

which mood stabilizer does not require TDM

A

lamotrigine

65
Q

lamotrigine indications

A

bipolar depression, maintenance therapy

66
Q

place in therapy lamotrigine

A

first line as monotherapy & combo therapy for depressive episodes

67
Q

what happens if patient misses more than 5 days of lamotrigine

A

restart titration

68
Q

t/f: there is a correlation between levels and effectiveness for lamotrigine

A

false: no TDM

69
Q

common side effects lamotrigine

A

n/v, rash, somnolence/fatigue

70
Q

serious side effects lamotrigine

A

SJS, TEN, angioedema, multi organ failure

71
Q

boxed warning for lamotrigine

A

life-threatening rashes (SJS & TEN)
higher in children than adults
coadministration w/ valproate

72
Q

baseline monitoring for lamotrigine

A

BUN, SCr, LFTs

73
Q

ongoing monitoring for lamotrigine

A

BUN, SCr, LFTs q6-12 months

74
Q

carbamazepine indications

A

bipolar disorder, mania or mixed episodes

75
Q

carbamazepine place in therapy

A

second line monotherapy & combo therapy for manic, hypomanic, mixed episodes

76
Q

carbamazepine is an ________

A

an autoinducer

77
Q

carbamazepine dosing

A

start at 400 mg/day (divided bid)
increase by 200 mg/day every week up to 1200

78
Q

therapeutic range carbamazepine

A

4-12

79
Q

what happens at carbamazepine levels >8

A

n/v, HA, dizzy, blurred vision

80
Q

what happens at carbamazepine levels >40

A

apnea, dystonia, coma

81
Q

boxed warning carbamazepine

A

serious derm reactions & HLA-B*1501 allele

aplastic anemia & agranulocytosis

82
Q

carbamazepine contraindications

A

bone marrow depression, concurrent MAOI use or NNRTI, hepatic failure

83
Q

warnings for carbamazepine

A

avoid if history of hepatic porphyria
increased risk suicidality
teratogen
potential for withdrawal seizure if abrupt dc
hyponatremia

84
Q

common side effects carbamazepine

A

n/v, blurred vision, dizzy, somnolence

85
Q

serious side effects carbamazepine

A

SJS, TEN, anemia, agranulocytosis, hepatic failure

86
Q

baseline monitoring carbamazepine

A

HLA-B*1502 allele if asian

CBC, LFT, BUN, SCr, lytes, pregnancy test

87
Q

when to monitor carbamazepine levels

A

5 days after dose adjustments
then every 6-12 months

88
Q

ongoing monitoring carbamazepine

A

CBC, LFT, BUN, SCr, lytes q6-12 months

89
Q

drugs that INCREASE carbamazepine levels

A

CCBs, cimetidine, erythromycin, valproic acid

90
Q

drugs that DECREASE carbamazepine levels

A

phenobarbital

91
Q

what does carbamazepine INDUCE

A

ITSELF (AUTO INDUCER)
and decreases oral hormonal contraceptives, theophylline, warfarin

92
Q

counseling for mood stabilizers (general)

A

stopping abruptly is bad (side effects, relapse)
many side effects are transient
lab monitoring
onset of effect

93
Q

adequate trial duration for mood stabilizers

A

2-3 weeks

94
Q

first line pharmacotherapy for bipolar

A

mood stabilizer or atypical antipsychotic

95
Q

atypical antipsychotics with FDA approval for bipolar 1 disorder

A

aripiprazole, asenapine, olanzapine, quetiapine, risperidone, ziprasidone, cariprazine, lurasidone, chlorpromazine, lumateperone

96
Q

first line for ACUTE MANIA

A

lithium, divalproex, risperidone, quetiapine, aripiprazole, ziprasidone, asenapine, paliperidone

97
Q

first line for ACUTE DEPRESSION

A

lithium, lamotrigine, quetiapine

98
Q

second line for ACUTE DEPRESSION

A

divalproex, lurasidone

neurology/psychiatry (22 decks)

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