Bipolar

Question 1

What drugs can induce mania?

Answer 1

Hallucinogenics e.g. LSD
CNS stimulants e.g. amphetamines, caffeine, ephedrine
Anti-depressants
Anti-psychotis e.g. quetiapine, olanzipine, risperidone

Question 2

Why don’t you give anti-depressants in bipolar?

Answer 2

because they can cause a switch to mania

Question 3

What is mania susceptible to?

Answer 3

Stresses e.g. change in time zone, irregular sleep, substance misuse

Question 4

What are the three areas of pharmacotherapy?

Answer 4

• 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

Question 5

Discuss prescribing principes in mania?

Answer 5

• 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

Question 6

What are some meds licensed in acute mania?

Answer 6

Lithium
Valproate
Olanzapine
Quetiapine
Aripiprazole

Question 7

What are some meds licensed in relapse prevention of mania?

Answer 7

Lithium
Valproate
Olanzapine
Quetiapine
Aripiprazole

Question 8

What are some meds licensed in acute bipolar depression?

Answer 8

lithium
quetiapine

Question 9

What are some meds licensed in relapse prevention of bipolar depression?

Answer 9

lithium
quetiapine

Question 10

What is the only drug licenced for management of acute bipolar depression in the Uk?

Answer 10

Quetiapine

Question 11

What baseline monitoring is required for Quetiapine?

Answer 11

Weight/BMI- can increase weight and risk of T2DM
Pulse
BP
Hba1c
Lipids
ECG- if at risk as can cause QT prolongation

Question 12

What are possible adverse effects of quetiapine?

Answer 12

Sleepiness
dizziness
dry mouth
weight gain
postural hypotension
headache
akathisia

Question 13

Why must initial dose titration of quetiapine be slow?

Answer 13

Initial dose titration must be slow due to the risk of postural hypotension in about 10% people

Question 14

What can you NOT give within an hour of short-acting IM Olanzapine?

Answer 14

Benzodiazepines - reports of DEATH

Question 15

When is lithium indicated?

Answer 15

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.

Question 16

What is important when prescribing lithium?

Answer 16

It is brand specific

Question 17

Where is Lithium contra-indicated and cautioned?

Answer 17

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

Question 18

can lithium be taken during pregnancy?

Answer 18

Avoid UNLESS in exceptional circumstances- especially in the first trimester as there is a risk of teratogenicity

Question 19

What monitoring is required prior to initiating lithium?

Answer 19

ECG
eGFR
Thyroid function- can be mistaken for depression
Weight/BMI
Calcium levels
U&Es
FBC

Question 20

What is a negative of lithium that can cause patients to not want to take?

Answer 20

It can cause increased weight gain up to 27kg. Average is 10kg

Question 21

What does Lithium require during treatment?

Answer 21

• Regular blood tests as it has a narrow therapeutic window. Ensures dose remains therapeutic and monitors for signs of toxicity.

Question 22

When should blood tests be taken on Lithium?

Answer 22

• 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)

Question 23

Who are the at risk categories requiring increased frequency of blood tests on lithium?

Answer 23

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+

Question 24

What should lithium levels be?

Answer 24

0.4 to 1mmol/L - higher end about 0.8 in mania

Question 25

When may lithium doses be decreased?

Answer 25

In renal impairment (avoid if poss)
Patients <50kg

Question 26

What are symptoms of lithium toxicity?

Answer 26

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

Question 27

What drugs can increase lithium levels?

Answer 27

• ACE inhibitors
• ARBs
• NSAIDs
• COx-2 inhibitors e.g. ketorolac- avoid
• Metronidazole
• SSRIs
• Diuretics- inc spironolactone, bumetanide, furosemide, bendroflumethiazide

Question 28

What drugs can decrease lithium levels?

Answer 28

Sodium bicarbonate-containing drugs
Caffeine