Bipolar Flashcards
What is considered Bipolar 1?
Mania of at least 1 week. DOES NOT need to have depressive episode
What is considered bipolar 2?
hypomania <4 days and needs depressive episode
What gender gets more manic episodes?
men
WHat are some risk factors for bipolar?
stress, trauma, substance abuse, having a first degree relative, depression, thyroid
What medications are good to know that can cause mania?
alcohol, weed, antidepressants, stimulants (dopamine), steroids, thyroid
How does bipolar usually present as?
depression
What is the kindling theory?
more episodes= vulnerable for more
What can happen if bipolar is not treated?
increasing impairment and deficits of brain
What must you always assess in each bipolar counsel?
SUICIDE RISK
What is criteria of mania?
Not due to other meds
3 of: grandiosity, no sleep, racing thoughts, talking, distracted, agitation, high risk behaviours.
What is criteria of depression?
5 of:
S-sleep
I-change in interest
G-guilt
E- energy
C-concentration
A-appetite
P-psychomotor disturbances
S- suicidal ideation
What depressants are worse for causing mania?
TCA
SNRI
SSRI
Mirtazapine
How long to see improvement of mania and depression?
Mania- 1-2 weeks- full is 3-4
Depression- 2-4 MAYBE LONGER
If a person is on lithium and is experiencing peak tremors, how can we fix it?
extended release
How is lithium excreted?
renal
What can decrease lithium clearance?
low salt, low water, renal disease, NSAID, ACE, diuretics
What is range of lithium for acute, maintenance, and elderly mania?
Acute- 1-1.2
Maintenance- 0.6-1
Elderly- 0.6-0.8
What level can induce toxic lithium levels?
> 1.2
What are signs of toxic lithium?
drowsy, ataxia, tremor, seizure arrythmia
When should you take lab work for lithium?
12 hours after dose
5-7 days after starting
What can we do if nausea from lithium?
divide dose
What happens if you are toxic on lithium?
if not dangerous then hold dose and retest after 24 hours
Common side effects of lithium?
thirst, peeing, tremor, drowsy, weight gain, nausea
If a patient is 20 yrs old and female and is given a lithium prescription what MUST you do?
birth control
What is divalproex?
prodrug of valproic acid
How does valproic acid work?
sodium channel inhibition and Increase GABA
In regards to PK and valproic acid what is good to know?
VERY protein bound= displacement interactions, hepatic
What is levels for valproic acid?
Not routinely done
If a person is in renal failure what is the dosing adjustment for valproic acid?
NONE :)
What interaction is high with valproic acid?
CYP2C9
What drugs are of high importance of increasing valproic acid levels?
Macrolides (mycins)
salicylates
What drugs are of high importance of decreasing valproic acid levels?
carbapenems
What drug increases (how much) from valproic acid and can be life threatening?
50 % increase Lamotrigine- SJS
When is divalproex a good choice for mania?
if irritable or AUD
What monitoring is needed for valproic acid?
CBC, electrolytes, LFT, RASH
S/e of valproic acid?
NDV constipation, sedation, weight, rash, hepatotoxic, AMMONIUM
A patient comes in with a prescription for valproic acid. She is 23 and married.
TERATOGENIC
What is lamotrigine used for?
DEPRESSION ONLY
How does lamotrigine work?
sodium and glutamate inhibitor
some serotonin
What is the therapeutic range for lamotrigine?
NONE
What drugs can induce metabolism of it?
phenytoin and CMZ
WHat is a good counselling tip for rash of lamotrigine?
no new lotions, detergents
In regards of titration of lamotrigine, how do we do it and why?
VERY slow due to SJS and TENS
What labs are needed for lamotrigine?
renal and hepatic
A 23 year old girl comes in with a lamotrigine prescription, what are we concerned about and why?
birth control- estrogen decreases lamotrigine
What do you do if you missed your meds of lamotrigine for 5 plus days?
NEW TITRATION
Why don’t we like CBZ?
drug interactions
When would CBZ be an interesting option for patients?
if neuropathic pain/ trigeminal neuralgia
How does CBZ work?
sodium channel inhibition and other
WHat hormone does CBZ influence in the body? (NOT neurology)
ADH- resorb more water
What is unique to CBZ regarding metabolism?
induces its own hepatic metabolism
When is steady state in CBZ?
5 weeks
In regards to CBZ most common s/e, what can we do?
if nausea then take with food and divided doses
A patient comes in with a new prescription of CBZ. What should be checked?
INTERACTIONS
Common drugs that increase CBZ?
macrolides, VA, diltiazem, verapamil, AZOLES, grapefruit
What drugs are an issue to be on if also on CBZ?
DOACS and warfarin
S/E of CBZ?
Gi, CNS depression, hyponatremia, low WBC, rash
What genotype in caucasian and asian increases chance of rash in CBZ?
Caucasian- HLA-A3101
Asian- HLA-B1502`
Who can’t take CBZ?
liver disease, low WBC, clozapine, CVD (HR and conduction issues)
A theme among bipolar medications is the use of BC. What is special for CBZ
NO ESTROGEN ONES
What supplementation should be done with CBZ?
vit D and calcium
Which is better atypical antipsychotics or regular?
atypical because less EPS (movement disorders)
What are typical side effects of atypical antipsychotics?
anticholinergic, EPS, sex dysfunction
What are some atypical antipsychotics?
risperidone, lurasidone, aripiprazole,
quetiapine
Which is more effective for bipolar depression, mood stabilizer or combo with antidepressant?
Both he same
What is an issue with the study that looked at combo of lithium and antidepressant for depression?
only 8 weeks long
If a person is on combo therapy for bipolar and enters a manic state, as a pharmacist what should you do?
taper off antidepressant
Which SSRI is NOT recommended in bipolar?
paroxetine
Should a person be on long term antidepressants if bipolar?
no, once stable for 3-4 months taper off
What is first line for acute mania?
lithium, quetiapine, divalproex, aripipirazole and risperidone
Is combo with mood stabilizer and antipsychotic more effective than mono for acute mania?
yes- use when need fast recovery
When is lithium more preferred for acute mania?
classic euphoria, low number of episodes and family history of it working
When is divalproex more preferred for acute mania?
equally effective in classic and dysphoric mania, better if multiple episodes, irritable or comorbid substance use
If no improvement for acute mania is it better to add or switch? and when can we assume no improvements?
after 2 weeks, either or
Which agents DO NOT work for acute mania?
gabapentin, lamotrigine, topiramate, and omega 3
What is first line for bipolar depression?
Quietiapine, lurasidone and lithium, lithium, lamotrigine
In regards to evidence for bipolar depression which agent is better quetiapine or lithium?
quetiapine
Which agents are NOT recommended for bipolar depression?
ANTIDEPRESSANTS
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?
don’t use quetiapine and use lurasidone
Is lithium or valproic acid better for maintenance of bipolar?
lithium
Is a combo of VA and lithium worth it?
yes -significantly
If acute phase meds work what should we use for maintenance?
SAME ONES
If you have mixed episode bipolar (switch rapidly or both), what agents to use?
atypical antipsychotics
Which agent to use in pregnant bipolar patients?
lamotrigine safe
neutral agents are quetiapine, risperidone, aripiprazole
If patient is suicidal and is taking lithium what should we don in regards to the medication itself?
don’t give a month as overdose is fatal
Which agent has the most evidence for prevent suicide in bipolar patients?
lithium
What agents do not appear to have no effect on suicide risk in bipolar patients?
antipsychotics
