bipolar Flashcards
Treatment for acute mania
D/C any antidepressants or stimulants
SGAs: aripiprazole, quetiapine, risperidone, asenapine, paliperidone, cariprazine
Lithium
Valproate
2nd:
carbamazepine (safety profile)
olanzapine
ziprasidone
haloperidol
Treatment for bipolar depression
quetiapine
lithium
lamotrigine
lurasidone
2nd:
valproate
olanzapine/fluoxetine
cariprazine
adjunctive SSRI/bupropion (never first line)
1st line maintenance therapy
lithium
valproate
lamotrigine
quetiapine
aripiprazole
asenapine
olanzapine-samidorphan
Lithium CI
pregnancy (cardiac malformations)
breastfeeding
renal impairment (Almost 100% renally eliminated unchanged)
dehydration
hyponatremia
severe cardiac disease
Lithium AE (within therapeutic range)
GI upset
cognitive effects
tremor
polyuria/polydipsia
weight gain
alopecia
leukocytosis
rash
somnolence/sedation
AKI
hypothyroidism
neurotoxicity (SILENT)
Lithium AE (toxicity)
> 1.5 coarse tremor, N/V/D
2.0 confusion, sedation, slurred speech
2.5 seizures, coma, death
Interactions that increase lithium levels
NSAIDs
decreased sodium intake / sodium loss
thiazide diuretics
ACEis, ARBs
calcium channel blockers
dehydration, sweating, diarrhea
prolonged fever
Interactions that decrease lithium levels
Loop diuretics
SGLT-2 inhibitors
carbonic anhydrase inhibitors
excessive sodium intake
excessive fluid intake
theophylline
caffeine
Valproate MoA
enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)
Valproate CI
hepatic disease
urea cycle disorders
pregnancy (neural tube defects, craniofacial defects, cardiovascular defects)
Valproate AE
N/V
Tremor
sedation
alopecia
weight gain
thrombocytopenia
LFT increase
hepatotoxicity (BBW)
encephalopathy
pancreatitis (BBW)
agranulocytosis
PCOS
metabolic syndrome
rash
Interactions that decrease valproate levels
carbamazepine
phenytoin
rifampin
combined oral contraceptives
Valproate has increased hepatotoxicity risk when combined with
topiramate
Valproate can increases levels of which drugs?
lamotrigine
lorazepam
Carbamazepine MoA
enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)
inhibits glutamate release
anti-kindling effect
What is Equetro?
the only form of carbamazepine approved for mania
What is considered toxic levels of carbamazepine?
> 15 mcg/mL
Carbamazepine CI
myelosuppression
hepatic disease
TCA hypersensitivity
pregnancy (cranial defects, cardiac malformations, neural tube defects)
Safer drugs to use for bipolar pregnant patients
SGAs
lamotrigine (not the best for mania)
lurasidone (for bipolar depression)
possibly chlorpromazine (only FGA approved for mania)
Carbamazepine AE
N/V
Drowsiness
ataxia, dizziness, confusion
blurred vision
hyponatremia (SIADH)
hematologic effects (BBW)
hepatotoxicity
rash (SJS, toxic epidermal necrolysis/TEN)
increase seizures (rarely)
Which agents have a warning for suicidal thoughts and behavior?
carbamazepine, valproate, lamotrigine (anticonvulsants)
NOT lithium - actually prevents suicide, self harm and death in mood disorder patients
Carbamazepine interactions
many CYP interactions (3A4, 2C9, 2C19, 1A2, 2B6)
decreases valproate and lamotrigine levels
autoinducer
decreases effectiveness of oral contraceptives
Carbamazepine CI
nefazodone
NNRTIs
MAOis
For patients with Asian ancestry, which allele should they be screened for, and for which drug? Why?
HLA-B*1502 allele
Before treatment on carbamazepine
Due to risk of SJS (flu-like symptoms, rash)
What agents have interactions with oral contraceptives?
valproate
carbamazepine
lamotrigine
topiramate
Lamotrigine MoA
inhibit voltage-sensitive Na+ channels
inhibit release of glutamate
weak 5-HT3 inhibitor
Lamotrigine AE
serious rash (SJS, toxic epidermal necrosis/TEN)
headache
somnolence
ataxia
diplopia (double vision)
tremor
dizziness
N/V
What are risk factors for experiencing serious rash when taking lamotrigine?
fast titration
high doses
co-administration with valproate
pediatric patients
cleft lip and palate (in pregnancy)
Which agents have warning for arrhythmia?
lamotrigine
lithium - not warning, but intermediate side effect
Lamotrigine Interactions
increased by valproate
decreased by carbamazepine
decreased efficacy by folic acid
hormonal contraceptives (estrogen, progestin)
Topiramate uses
limited data for monotherapy
mostly as adjunctive therapy or to treat AE/comorbidities (weight loss, alcohol use disorder)
may decrease efficacy of oral contraceptives
Gabapentin uses
limited data for mood benefits
mostly to treat comorbidities (anxiety, pain, insomnia)
What are FDA approved options for SGA maintenance treatment?
Abilify Maintena (aripiprazole once monthly LAI)
Risperidal Consta (risperidone microsphere LAI)
When can antidepressants be used for bipolar disorder?
only during acute depressive phase (SSRI or bupropion)
only in combination with anti-manic agents
especially in bipolar I, recent mania, or rapid cycling
