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PHAR 358 M1 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

BP1 criteria?

A

Full manic episode of at least 1 week; epsiode consist of abnormally and persistently elevated mood and increased energy

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2
Q

BP2 criteria?

A

hypomanic episode, current or past, and major depressive episode either current or past

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3
Q

Cause of Bipolar?

A

Unknown, theories involving NTs and signal transduction have been proposed

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4
Q

Bipolar risk factors?

A

Drug/alcohol use
First degree relative w/ BP
period of high stress
Major life changes such as death of a loved one or traumatic experience
Medical conditons including: hypothyroidism, hormonal changes, CNS dsiroders, dysregulation, CVD

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5
Q

What are the secndary causes of mania?

A

Alcohol intoxication
Drug withdrawal
Antidepressants
Dopamine augmenting agents (stimulants, DA reuptake inhibtors/ releasers/ agonists)
Marijuana
Norepinepherine augmenting agents
Steroids
Thyroid preparations

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6
Q

Average age of onset for BP?

A

20-25

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7
Q

What is the kindling theory?

A

abnormalities lead to more abnormalities, syndromal episodes increase vunerability to more episodes

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8
Q

What % of BP patients d/c meds b/c of AEs?

A

~50%

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9
Q

What comorbid conditons may worsen existing BP or make treatment challenging?

A

Anxiety disorders
Substance use disorder
ADHD
PTSD
Diabetes
dyslipedemia
obesity
CVD

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10
Q

How much is suicide risk increased in those with BP vs general population?

A

20x increased,
6-7% of BP pts die by suicide

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11
Q

Mania diagnostic criteria?

A

atleast 3 of;
grandiosity or inflated self esteem
decreased need for sleep
racing thoughts
increased talking/pressured speech
distractability
increased goal-directed pr psychomotor agitation
excessive engagement in high risk behaviours;
and must occur nearly every day for atleast 1 week, and epsidoe is not due to physiological effects of a substance or another medical condition

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12
Q

What does DIGFAST stand for?

A

Mani mnemonic;
Distractibility
Irratibility or indiscretion
Grandiosity
Flight of ideas
Activity increased
Sleep decreased
Talkative

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13
Q

Are hypomanic/ major depressive episodes needed for diagnosis of BP1?

A

No just manic episode >1 week

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14
Q

What is the key difference in a hypomanic episode vs a manic episode?

A

Duration; hypomanic is 4 or less days vs 7+ days for manic episode

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15
Q

Key differnet features of BP1 vs BP2

A

Functional impairment for BP1
Psycotic features for BP1
Required hospitazlization for BP1
History of depression for BP2

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16
Q

Major Depressive episode daignostic criteria?

A

5+ of SIGECAPS + Depressed mood most of the day neraly every day, diminished interst or pleasure in all or most activites
Sleep pattern change
Interest/acitivty change
Guilt or increased worry
Energy level changes
Concnetration level changes
Appetite level changes
Psychomotor disturbances
Suicidal ideation

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17
Q

What rating scale can be used to help screen for Bipolar disease (especially BP1)?

A

Mood disorders questionare (MDQ)

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18
Q

Rate from worst to least for manic risk;
Mirtazipine, TCAs, SSRI, SNRI

A

TCA/SNRI
SSRI
Mirtazipine

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19
Q

What is BP the most misdiagnosed with?

A

depression

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20
Q

What are the 3 challenges in BP diagnosis/treatment?

A

Delay of diagnosis
Misdiagnosis
Limited Clinical trials

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21
Q

What are the 8 goals of therapy for BP therapy?

A
  1. Eliminate mood episode with complete remission of sx (acute treatment)
  2. Prevent recurrence or relapse (Maintanence treatment)
  3. improve QoL and optomize pschosocial functioning
  4. Minimize harm to slef and others
  5. Maximize adherence and minimize AEs of pharmacotherapy
  6. Identify and minimize risk factors for mood episodes
  7. Povide care for comorbid pschiatirc, substance use, or medical conditions
  8. Provide education to pt and family members
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22
Q

How long does it take to see response from therapy with mania? full clinical benefit?

A

1-2 weeks
3-4 weeks

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23
Q

How long does it take to see a response w/ depression? Full clinical benefit?

A

2-4 weeks (but bipolar depression may take longer)
6-12 weeks

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24
Q

What is WRAP?

A

Wellness Recovery Action Plan;
list early sx; basically plan of catching hypomania and what to do

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25
Q

When would lamotrigine or carbamazepine be used more for Bipolar?

A

When seizures are present as well

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26
Q

What can occur when edema is present w/ Lithium?

A

It can accumulate as it distributes evenly in total body warer space

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27
Q

How is Lithium primarily elimianted?

A

Renally; freely filtered by glomerulus like Na and K, large amount reabsorbed in proximal tubule

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28
Q

What can decrease Lithium clearance?

A

hyponatremia, dehydration, renal failure or dysfunction, decreased renal blood flow

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29
Q

What 3 main drug classes have the potential to cause Lithium toxicity?

A

NSAIDs
ACEI
THiazide diuretics

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30
Q

What are the Lithium level targets for;
Acute Mania
Maintanence Therapy
Elderly

A

1-1.2 –> or 0.8-1.2 2 different ranges in notes
0.6-1
0.6-0.8

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31
Q

When are Lithium levels drawn?

A

12 hours post dose

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32
Q

What is the frequency of Lithium sampling?

A

5-7 days after starting/changing dose, then once weekly until stabilized for 2 weeks then, monthly for up to 3 months, then atleast every 6 months

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33
Q

When would newly started lithium reach steady state?

A

5 half lives T1/2 approx 24hrs therfore 5 days

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34
Q

How do you do a lithium dose correction

A

Current dose/Current plasma level = X dose/Taret plasma level

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35
Q

Examples that lower lithium levels?

A

Preganancy
Na supplements*****
Hemodialysis
Peritoneal dialysis
Burns
THeophyline
Caffeine
Acetazolamide
Sodium Bicarbonate

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36
Q

Examples that increase Lithium levels?

A

NSAIDs*
Thiazide diuretics*
ACEi/ARBs **
Na loss *
SSRI/SNRI possibly
Renal impairment

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37
Q

WHen is there an increased risk of neurotoxicity with Lithium?

A

When used w/ antipsychotics or carbamazepine

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38
Q

What are the 5 main drug classes that have drug interactions with Lithium?

A

Diuretics
NSAIDs
ACEi
Antipsychotics
Antidepressants

39
Q

Common Lithium SEs?

A

Thirst + increased urination frequency
Headaches
Sedation
Weakness
Tremors
Skin changes
Wt gain (4-6kg in first 2 years)
Alopecia

40
Q

Serious Lithium SEs?

A

hypothyroidism
Renal Injury
Blood dyscrasias
Bradycardia
Nephrogenic diabetes insipidus
polydipsia
polyuria

41
Q

Toxic effects of Lithium at ~1.5mmol/L?

A

ataxia
fine tremors
GI disturbances
muscle weakness, fatigue

42
Q

Toxic effects of Lithium at 1.5-2.5 mmol/L

A

sedation
lethargy
ataxia
dysarhtia
headhaces
increased reflexes
hyperthermia
course tremors
impaired sensorium
nystagmus

43
Q

Toxic effects of Lithium at > 2.5mmol/L?

A

Coarse tremors
delirium
seizures
coma
respiratory complications
death

44
Q

Lithium Monitoring Plan?

A

Mania, depressive sx–> daily/monthly by pt and pharmacist
CBC q12m
Wt q6-12m
Electrolytes, TSH, Renal function q2-3m x 6m, then q6-12m as clincially indicated
ECG –> as clinically indicated
Lithium levels (in other card)
Adherence
SEs
Suicide risk at all appointments

45
Q

What would happen to Lithium if:
- Eat lots of slaty foods
- Hot yoga
- Stopping caffeine
- Starting NSAID
- 2nd trimester of pregnancy
- increased fluid intake

A
  • Eat lots of slaty foods -
  • Hot yoga +
  • Stopping caffeine +
  • Starting NSAID +
  • 2nd trimester of pregnancy -
  • increased fluid intake -
46
Q

Valproic Acid Indications?

A

Seizures
BP disorder both acute mania and maintenance

47
Q

Valproic acid elimination?

A

hepatic; glucoronidation and B-oxidation

48
Q

What Valproic acid metabolite can cause liver toxicity?

A

4-ene-VP

49
Q

Therapeutic range of VPA?

A

350-700 micromol/L

50
Q

WHen to take VPA steady state trough level?

A

3-4 days after intial therapy

51
Q

VP enzyme interactions?

A

CYP2C9, epoxide hydroxylase, UDPGT

52
Q

Drugs to know that increase VPA?

A

Macrolides (clarithromycin)
ASA
Carbapenems
LAMOTRIGINE

53
Q

What % should VPA be reduced if lamotrigine on board?

A

50%

54
Q

VPA AE’s?

A

GI: NVD, constipation
CNS: tremors, sedation, ataxia, dizziness
wt gain

55
Q

VPA safe in pregnancy?

A

NO teratogenic

56
Q

VPA monitoring?

A

Sedation
CBC and LFTs: baseline, then monthly q3m, then q4-6m
Rash
VPA levels 2-4 days after dose change, 1-2 weeks after starting DI
Ammonia if unexplained confusion, lethargy, vomitting

57
Q

Lamotrigine good for mainia?

A

Not great, better for depressive side of BP

58
Q

Lamotirgine indications?

A

Seizures
BP: acute depression, maintenance in BP 1/2

59
Q

Lamotirgine MOA?

A

Alters signal transduction via voltage NA, reducing glutamate
Weak %-HT3 receptor inhibition

60
Q

VPA MOA (general)

A

Inhibtion of NA voltage channels
Increasing action of GABA
Modulates signal transduction cascades and gene expression
Effects on Serotonin, Dopamine, aspartate, T-type Ca channels

61
Q

Why titrate lamotrigine slow?

A

SJS and TENS risk

62
Q

When must you restart lamotrigine titration?

A

After 5 days missed doses

63
Q

Common SE of Lamotrigine?

A

Sedation, headaches, nausea, dizziness

64
Q

Rare SEs of lamotrigine?

A

SJS
aseptic meningitis
blood dyscrasias
hepatotoxicity

65
Q

Lamotrigne or VPA more sedation?

A

VPA

66
Q

Lamotrigine monitoring?

A

hepatic and renal function
rash

67
Q

Lamotrigine DIs?

A

VPA (increase 2x)
Carbamazdpine (decrease 30-50%)
oral contraception (decrease levels by~50%)

68
Q

Why tapper off of lamotrigine?

A

may trigger seizure even w/o seizure history

69
Q

Carbamazepine Indications?

A

Seizures
BP: acute mania, maintenance
Trigeminal neuralgia

70
Q

Carbamazepine MOA?

A

blocks vltage NA channels
stimulates release of ADH, promoting reabsorption of water
blocks NMDA glutamate receptors, modulates aspartate and glutamate release

71
Q

Carbamazepine elimination?

A

hepatic; CYP3A4, CYP2C8, CYP1A2

72
Q

Unique metabolism of carbamazepine?

A

autoinduction of its own metabolism

73
Q

Why is carbamazepine not used as much in Bipolar?

A

b/c interactions, autoinduction

74
Q

Frequency of sampling for carbamazepine?

A

every 1-2 weeks until stable regimen, steady stte trough after 5 weeks

75
Q

Why titrate slow for carbamazepine

A

to minimize AEs, sedation and GI can be bad so doses divided can help too

76
Q

Drugs that increase carbamazepine levels?

A

Macolides
Azoles
CCBs
Grapfruit juice

77
Q

Drugs that decrease carbamazepine levels?

A

Warfarin
DOACs
lurasidone (APs)
estrogen or progesterone contraceptives
Methadone

78
Q

Carbamazepine AEs?

A

GI: NVC, anorexia, dry mouth
CNS: lethargy, dizziness, sedation, hedache, ataxia, blurred vision
CV: tachycardia, hypotension
hyponatremia
blood dyscrasias
Rash

79
Q

What postive genetic test increases risk for rash w/ carbamazepine (Asian and Caucasian)

A

Asian: HLA-B1502
Caucasian: HLA-A3101

80
Q

what WBC warrants d/c of carbamazepine?

A

<2x10^9/L

81
Q

Carbamazepine CIs?

A

History of hepatic disease, CVD, blood dyscrasias, bone marrow depression
Concurrent use with clozapine

82
Q

Carbamazepine monitoring?

A

CNS
HEENT(ocular exam)
CVS(ECG)
CBC and electrolytes
LFTs
Renal function
TSH
BMD
Rash

83
Q

Antipsychotics MOA?

A

Dopamine blockade

84
Q

atypical or typical APs used more in Bipolar?

A

atypical

85
Q

are psychosis doses or Bipolar doses higher for APs?

A

lower for bipolar

86
Q

AP AEs?

A

EPS
hyperprolactinemia, sexual dysfunction
metabolic disturbances
anticholinergic: sedation
antihistaminergic
hypotension, dizziness, tachycardia
QT prolongation
seizures

87
Q

Acute mania 1st line therapies:

A

Mono: Lithium, quetiapine, VPA, aripiprazole, paliperidone (>6mg), risperidone
Combo: Lithium or VPA + quetiapine, risperidone, asenapine

88
Q

When is VPA reccomended over Lithium

A

more episodes

89
Q

Bipolar 1 depression 1st line?

A

Quetiapine, lurasidone + Lithium or VPA, Lithium, lamotrigine mono or adjunct

90
Q

Bipolar 1 maintenance 1st line?

A

Lithium
Quetiapine
VPA
Lamotrigine
Asenapine
Aripiprazole
Lithium/VPA + quetiapine or aripiprazole

91
Q

Mixed episodes recommended pharmacotherapy?

A

d/c antidepressants
monotherapy of atypical AP or combo w/ Lithium or VPA

92
Q

Treatment in pregnancy?

A

AVOID: VPA, Carbamazepine
small increased risk in trimester 1 w/ Lithium if using use lowest effective dose
Least risk: Lamotrigine
APs least studied but risk appears neutral for quetiapine, risperidone, aripiprazole, olanzapine

93
Q

Which med has best evidence for suicide prevention in Bipolar?

A

Lithium; but overdose is fatal so dispensing may need to be altered

PHAR 358 M1 (2 decks)

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