Bipolar Flashcards
What drugs can induce mania?
Hallucinogenics e.g. LSD
CNS stimulants e.g. amphetamines, caffeine, ephedrine
Anti-depressants
Anti-psychotis e.g. quetiapine, olanzipine, risperidone
Why don’t you give anti-depressants in bipolar?
because they can cause a switch to mania
What is mania susceptible to?
Stresses e.g. change in time zone, irregular sleep, substance misuse
What are the three areas of pharmacotherapy?
- Mood stabilisation and relapse prevention- decrease frequency and severity of episodes
- Acute hypomania/mania- management and decrease harm in episodes
- BP depression- acute management of bp depression
Discuss prescribing principes in mania?
- Discontinue any manicogenic agents e.g. ADs, stimulants
- Start non-specific calming meds e.g. Benzodiazepines, anti-psychotics
- Start specific mood stabilisers
- consider hypnotic or sedative- sleep deprivation can worsen mania
What are some meds licensed in acute mania?
Lithium
Valproate
Olanzapine
Quetiapine
Aripiprazole
What are some meds licensed in relapse prevention of mania?
Lithium
Valproate
Olanzapine
Quetiapine
Aripiprazole
What are some meds licensed in acute bipolar depression?
lithium
quetiapine
What are some meds licensed in relapse prevention of bipolar depression?
lithium
quetiapine
What is the only drug licenced for management of acute bipolar depression in the Uk?
Quetiapine
What baseline monitoring is required for Quetiapine?
Weight/BMI- can increase weight and risk of T2DM
Pulse
BP
Hba1c
Lipids
ECG- if at risk as can cause QT prolongation
What are possible adverse effects of quetiapine?
Sleepiness
dizziness
dry mouth
weight gain
postural hypotension
headache
akathisia
Why must initial dose titration of quetiapine be slow?
Initial dose titration must be slow due to the risk of postural hypotension in about 10% people
What can you NOT give within an hour of short-acting IM Olanzapine?
Benzodiazepines - reports of DEATH
When is lithium indicated?
Prophylaxis of bipolar
- in acute manic or hypomanic episodes- it must have had previous response
- Gold standard for relapse prevention
- Rarely used in mania (like above?) as it has a 5-7 day delayed onset.
What is important when prescribing lithium?
It is brand specific
Where is Lithium contra-indicated and cautioned?
Cardiac disease
cardiac insufficience
- As lithium affects QT interval
Severe renal impairment- is renally excreted
Hypothyroidism
breastfeeding
Addisons disease
Cautioned:
- Pregnancy
- Mild to moderate renal impairement
- other meds that decrease epileptic threshold
- other meds that increase QT prolongation
can lithium be taken during pregnancy?
Avoid UNLESS in exceptional circumstances- especially in the first trimester as there is a risk of teratogenicity
What monitoring is required prior to initiating lithium?
ECG
eGFR
Thyroid function- can be mistaken for depression
Weight/BMI
Calcium levels
U&Es
FBC
What is a negative of lithium that can cause patients to not want to take?
It can cause increased weight gain up to 27kg. Average is 10kg
What does Lithium require during treatment?
- Regular blood tests as it has a narrow therapeutic window. Ensures dose remains therapeutic and monitors for signs of toxicity.
When should blood tests be taken on Lithium?
- Take weekly until stable concentrations for 4 weeks
- Nice recommended plasma levels evert 3 months for 1 year and then 6-monthly thereafter unless in an at risk group (another flashcard)
Who are the at risk categories requiring increased frequency of blood tests on lithium?
Elderly
On drugs that interact with lithium
risk of renal or thyroid impairment
increased calcium levels
poor symptoms control
poor adherence
if plasma levels were 0.8mmol/L+
What should lithium levels be?
0.4 to 1mmol/L - higher end about 0.8 in mania
When may lithium doses be decreased?
In renal impairment (avoid if poss)
Patients <50kg
What are symptoms of lithium toxicity?
Severe hand tremor
Stomach ache, nausea, diarrhoea
Blurred vision
confusion
mUSCLE TWITCHES
unsteadiness
Slurring words
Sleepy
Severe:
Convulsions
Coma
Renal and circulatory failure
Toxic psychoses
What drugs can increase lithium levels?
- ACE inhibitors
- ARBs
- NSAIDs
- COx-2 inhibitors e.g. ketorolac- avoid
- Metronidazole
- SSRIs
- Diuretics- inc spironolactone, bumetanide, furosemide, bendroflumethiazide
What drugs can decrease lithium levels?
Sodium bicarbonate-containing drugs
Caffeine
