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pharmacy 358 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

What is considered Bipolar 1?

A

Mania of at least 1 week. DOES NOT need to have depressive episode

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2
Q

What is considered bipolar 2?

A

hypomania <4 days and needs depressive episode

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3
Q

What gender gets more manic episodes?

A

men

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4
Q

WHat are some risk factors for bipolar?

A

stress, trauma, substance abuse, having a first degree relative, depression, thyroid

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5
Q

What medications are good to know that can cause mania?

A

alcohol, weed, antidepressants, stimulants (dopamine), steroids, thyroid

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6
Q

How does bipolar usually present as?

A

depression

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7
Q

What is the kindling theory?

A

more episodes= vulnerable for more

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8
Q

What can happen if bipolar is not treated?

A

increasing impairment and deficits of brain

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9
Q

What must you always assess in each bipolar counsel?

A

SUICIDE RISK

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10
Q

What is criteria of mania?

A

Not due to other meds
3 of: grandiosity, no sleep, racing thoughts, talking, distracted, agitation, high risk behaviours.

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11
Q

What is criteria of depression?

A

5 of:
S-sleep
I-change in interest
G-guilt
E- energy
C-concentration
A-appetite
P-psychomotor disturbances
S- suicidal ideation

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12
Q

What depressants are worse for causing mania?

A

TCA
SNRI
SSRI
Mirtazapine

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13
Q

How long to see improvement of mania and depression?

A

Mania- 1-2 weeks- full is 3-4
Depression- 2-4 MAYBE LONGER

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14
Q

If a person is on lithium and is experiencing peak tremors, how can we fix it?

A

extended release

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15
Q

How is lithium excreted?

A

renal

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16
Q

What can decrease lithium clearance?

A

low salt, low water, renal disease, NSAID, ACE, diuretics

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17
Q

What is range of lithium for acute, maintenance, and elderly mania?

A

Acute- 1-1.2
Maintenance- 0.6-1
Elderly- 0.6-0.8

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18
Q

What level can induce toxic lithium levels?

A

> 1.2

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19
Q

What are signs of toxic lithium?

A

drowsy, ataxia, tremor, seizure arrythmia

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20
Q

When should you take lab work for lithium?

A

12 hours after dose
5-7 days after starting

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21
Q

What can we do if nausea from lithium?

A

divide dose

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22
Q

What happens if you are toxic on lithium?

A

if not dangerous then hold dose and retest after 24 hours

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23
Q

Common side effects of lithium?

A

thirst, peeing, tremor, drowsy, weight gain, nausea

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24
Q

If a patient is 20 yrs old and female and is given a lithium prescription what MUST you do?

A

birth control

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25
Q

What is divalproex?

A

prodrug of valproic acid

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26
Q

How does valproic acid work?

A

sodium channel inhibition and Increase GABA

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27
Q

In regards to PK and valproic acid what is good to know?

A

VERY protein bound= displacement interactions, hepatic

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28
Q

What is levels for valproic acid?

A

Not routinely done

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29
Q

If a person is in renal failure what is the dosing adjustment for valproic acid?

A

NONE :)

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30
Q

What interaction is high with valproic acid?

A

CYP2C9

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31
Q

What drugs are of high importance of increasing valproic acid levels?

A

Macrolides (mycins)
salicylates

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32
Q

What drugs are of high importance of decreasing valproic acid levels?

A

carbapenems

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33
Q

What drug increases (how much) from valproic acid and can be life threatening?

A

50 % increase Lamotrigine- SJS

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34
Q

When is divalproex a good choice for mania?

A

if irritable or AUD

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35
Q

What monitoring is needed for valproic acid?

A

CBC, electrolytes, LFT, RASH

36
Q

S/e of valproic acid?

A

NDV constipation, sedation, weight, rash, hepatotoxic, AMMONIUM

37
Q

A patient comes in with a prescription for valproic acid. She is 23 and married.

A

TERATOGENIC

38
Q

What is lamotrigine used for?

A

DEPRESSION ONLY

39
Q

How does lamotrigine work?

A

sodium and glutamate inhibitor
some serotonin

40
Q

What is the therapeutic range for lamotrigine?

A

NONE

41
Q

What drugs can induce metabolism of it?

A

phenytoin and CMZ

42
Q

WHat is a good counselling tip for rash of lamotrigine?

A

no new lotions, detergents

43
Q

In regards of titration of lamotrigine, how do we do it and why?

A

VERY slow due to SJS and TENS

44
Q

What labs are needed for lamotrigine?

A

renal and hepatic

45
Q

A 23 year old girl comes in with a lamotrigine prescription, what are we concerned about and why?

A

birth control- estrogen decreases lamotrigine

46
Q

What do you do if you missed your meds of lamotrigine for 5 plus days?

A

NEW TITRATION

47
Q

Why don’t we like CBZ?

A

drug interactions

48
Q

When would CBZ be an interesting option for patients?

A

if neuropathic pain/ trigeminal neuralgia

49
Q

How does CBZ work?

A

sodium channel inhibition and other

50
Q

WHat hormone does CBZ influence in the body? (NOT neurology)

A

ADH- resorb more water

51
Q

What is unique to CBZ regarding metabolism?

A

induces its own hepatic metabolism

52
Q

When is steady state in CBZ?

A

5 weeks

53
Q

In regards to CBZ most common s/e, what can we do?

A

if nausea then take with food and divided doses

54
Q

A patient comes in with a new prescription of CBZ. What should be checked?

A

INTERACTIONS

55
Q

Common drugs that increase CBZ?

A

macrolides, VA, diltiazem, verapamil, AZOLES, grapefruit

56
Q

What drugs are an issue to be on if also on CBZ?

A

DOACS and warfarin

57
Q

S/E of CBZ?

A

Gi, CNS depression, hyponatremia, low WBC, rash

58
Q

What genotype in caucasian and asian increases chance of rash in CBZ?

A

Caucasian- HLA-A3101
Asian- HLA-B1502`

59
Q

Who can’t take CBZ?

A

liver disease, low WBC, clozapine, CVD (HR and conduction issues)

60
Q

A theme among bipolar medications is the use of BC. What is special for CBZ

A

NO ESTROGEN ONES

61
Q

What supplementation should be done with CBZ?

A

vit D and calcium

62
Q

Which is better atypical antipsychotics or regular?

A

atypical because less EPS (movement disorders)

63
Q

What are typical side effects of atypical antipsychotics?

A

anticholinergic, EPS, sex dysfunction

64
Q

What are some atypical antipsychotics?

A

risperidone, lurasidone, aripiprazole,
quetiapine

65
Q

Which is more effective for bipolar depression, mood stabilizer or combo with antidepressant?

A

Both he same

66
Q

What is an issue with the study that looked at combo of lithium and antidepressant for depression?

A

only 8 weeks long

67
Q

If a person is on combo therapy for bipolar and enters a manic state, as a pharmacist what should you do?

A

taper off antidepressant

68
Q

Which SSRI is NOT recommended in bipolar?

A

paroxetine

69
Q

Should a person be on long term antidepressants if bipolar?

A

no, once stable for 3-4 months taper off

70
Q

What is first line for acute mania?

A

lithium, quetiapine, divalproex, aripipirazole and risperidone

71
Q

Is combo with mood stabilizer and antipsychotic more effective than mono for acute mania?

A

yes- use when need fast recovery

72
Q

When is lithium more preferred for acute mania?

A

classic euphoria, low number of episodes and family history of it working

73
Q

When is divalproex more preferred for acute mania?

A

equally effective in classic and dysphoric mania, better if multiple episodes, irritable or comorbid substance use

74
Q

If no improvement for acute mania is it better to add or switch? and when can we assume no improvements?

A

after 2 weeks, either or

75
Q

Which agents DO NOT work for acute mania?

A

gabapentin, lamotrigine, topiramate, and omega 3

76
Q

What is first line for bipolar depression?

A

Quietiapine, lurasidone and lithium, lithium, lamotrigine

77
Q

In regards to evidence for bipolar depression which agent is better quetiapine or lithium?

A

quetiapine

78
Q

Which agents are NOT recommended for bipolar depression?

A

ANTIDEPRESSANTS

79
Q

If bipolar depression and weight gain is an issue which agent would you hold off on and which agent would you start if good coverage?

A

don’t use quetiapine and use lurasidone

80
Q

Is lithium or valproic acid better for maintenance of bipolar?

A

lithium

81
Q

Is a combo of VA and lithium worth it?

A

yes -significantly

82
Q

If acute phase meds work what should we use for maintenance?

A

SAME ONES

83
Q

If you have mixed episode bipolar (switch rapidly or both), what agents to use?

A

atypical antipsychotics

84
Q

Which agent to use in pregnant bipolar patients?

A

lamotrigine safe
neutral agents are quetiapine, risperidone, aripiprazole

85
Q

If patient is suicidal and is taking lithium what should we don in regards to the medication itself?

A

don’t give a month as overdose is fatal

86
Q

Which agent has the most evidence for prevent suicide in bipolar patients?

A

lithium

87
Q

What agents do not appear to have no effect on suicide risk in bipolar patients?

A

antipsychotics

pharmacy 358 (12 decks)

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