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bipolar Flashcards

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1
Q

Treatment for acute mania

A

D/C any antidepressants or stimulants

SGAs: aripiprazole, quetiapine, risperidone, asenapine, paliperidone, cariprazine
Lithium
Valproate

2nd:
carbamazepine (safety profile)
olanzapine
ziprasidone
haloperidol

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2
Q

Treatment for bipolar depression

A

quetiapine
lithium
lamotrigine
lurasidone

2nd:
valproate
olanzapine/fluoxetine
cariprazine
adjunctive SSRI/bupropion (never first line)

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3
Q

1st line maintenance therapy

A

lithium
valproate
lamotrigine
quetiapine
aripiprazole
asenapine
olanzapine-samidorphan

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4
Q

Lithium CI

A

pregnancy (cardiac malformations)
breastfeeding
renal impairment (Almost 100% renally eliminated unchanged)
dehydration
hyponatremia
severe cardiac disease

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5
Q

Lithium AE (within therapeutic range)

A

GI upset
cognitive effects
tremor
polyuria/polydipsia
weight gain
alopecia
leukocytosis
rash
somnolence/sedation
AKI
hypothyroidism
neurotoxicity (SILENT)

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6
Q

Lithium AE (toxicity)

A

> 1.5 coarse tremor, N/V/D
2.0 confusion, sedation, slurred speech
2.5 seizures, coma, death

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7
Q

Interactions that increase lithium levels

A

NSAIDs
decreased sodium intake / sodium loss
thiazide diuretics
ACEis, ARBs
calcium channel blockers
dehydration, sweating, diarrhea
prolonged fever

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8
Q

Interactions that decrease lithium levels

A

Loop diuretics
SGLT-2 inhibitors
carbonic anhydrase inhibitors
excessive sodium intake
excessive fluid intake
theophylline
caffeine

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9
Q

Valproate MoA

A

enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)

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10
Q

Valproate CI

A

hepatic disease
urea cycle disorders
pregnancy (neural tube defects, craniofacial defects, cardiovascular defects)

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11
Q

Valproate AE

A

N/V
Tremor
sedation
alopecia
weight gain
thrombocytopenia
LFT increase
hepatotoxicity (BBW)
encephalopathy
pancreatitis (BBW)
agranulocytosis
PCOS
metabolic syndrome
rash

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12
Q

Interactions that decrease valproate levels

A

carbamazepine
phenytoin
rifampin
combined oral contraceptives

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13
Q

Valproate has increased hepatotoxicity risk when combined with

A

topiramate

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14
Q

Valproate can increases levels of which drugs?

A

lamotrigine
lorazepam

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15
Q

Carbamazepine MoA

A

enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)
inhibits glutamate release
anti-kindling effect

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16
Q

What is Equetro?

A

the only form of carbamazepine approved for mania

17
Q

What is considered toxic levels of carbamazepine?

A

> 15 mcg/mL

18
Q

Carbamazepine CI

A

myelosuppression
hepatic disease
TCA hypersensitivity
pregnancy (cranial defects, cardiac malformations, neural tube defects)

19
Q

Safer drugs to use for bipolar pregnant patients

A

SGAs
lamotrigine (not the best for mania)
lurasidone (for bipolar depression)
possibly chlorpromazine (only FGA approved for mania)

20
Q

Carbamazepine AE

A

N/V
Drowsiness
ataxia, dizziness, confusion
blurred vision
hyponatremia (SIADH)
hematologic effects (BBW)
hepatotoxicity
rash (SJS, toxic epidermal necrolysis/TEN)
increase seizures (rarely)

21
Q

Which agents have a warning for suicidal thoughts and behavior?

A

carbamazepine, valproate, lamotrigine (anticonvulsants)

NOT lithium - actually prevents suicide, self harm and death in mood disorder patients

22
Q

Carbamazepine interactions

A

many CYP interactions (3A4, 2C9, 2C19, 1A2, 2B6)
decreases valproate and lamotrigine levels
autoinducer
decreases effectiveness of oral contraceptives

23
Q

Carbamazepine CI

A

nefazodone
NNRTIs
MAOis

24
Q

For patients with Asian ancestry, which allele should they be screened for, and for which drug? Why?

A

HLA-B*1502 allele
Before treatment on carbamazepine
Due to risk of SJS (flu-like symptoms, rash)

25
Q

What agents have interactions with oral contraceptives?

A

valproate
carbamazepine
lamotrigine
topiramate

26
Q

Lamotrigine MoA

A

inhibit voltage-sensitive Na+ channels
inhibit release of glutamate
weak 5-HT3 inhibitor

27
Q

Lamotrigine AE

A

serious rash (SJS, toxic epidermal necrosis/TEN)
headache
somnolence
ataxia
diplopia (double vision)
tremor
dizziness
N/V

28
Q

What are risk factors for experiencing serious rash when taking lamotrigine?

A

fast titration
high doses
co-administration with valproate
pediatric patients
cleft lip and palate (in pregnancy)

29
Q

Which agents have warning for arrhythmia?

A

lamotrigine
lithium - not warning, but intermediate side effect

30
Q

Lamotrigine Interactions

A

increased by valproate
decreased by carbamazepine
decreased efficacy by folic acid
hormonal contraceptives (estrogen, progestin)

31
Q

Topiramate uses

A

limited data for monotherapy
mostly as adjunctive therapy or to treat AE/comorbidities (weight loss, alcohol use disorder)
may decrease efficacy of oral contraceptives

32
Q

Gabapentin uses

A

limited data for mood benefits
mostly to treat comorbidities (anxiety, pain, insomnia)

33
Q

What are FDA approved options for SGA maintenance treatment?

A

Abilify Maintena (aripiprazole once monthly LAI)
Risperidal Consta (risperidone microsphere LAI)

34
Q

When can antidepressants be used for bipolar disorder?

A

only during acute depressive phase (SSRI or bupropion)
only in combination with anti-manic agents
especially in bipolar I, recent mania, or rapid cycling

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