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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
When would lamotrigine or carbamazepine be used more for Bipolar?
When seizures are present as well
26
What can occur when edema is present w/ Lithium?
It can accumulate as it distributes evenly in total body warer space
27
How is Lithium primarily elimianted?
Renally; freely filtered by glomerulus like Na and K, large amount reabsorbed in proximal tubule
28
What can decrease Lithium clearance?
hyponatremia, dehydration, renal failure or dysfunction, decreased renal blood flow
29
What 3 main drug classes have the potential to cause Lithium toxicity?
NSAIDs ACEI THiazide diuretics
30
What are the Lithium level targets for; Acute Mania Maintanence Therapy Elderly
1-1.2 --> or 0.8-1.2 2 different ranges in notes 0.6-1 0.6-0.8
31
When are Lithium levels drawn?
12 hours post dose
32
What is the frequency of Lithium sampling?
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
33
When would newly started lithium reach steady state?
5 half lives T1/2 approx 24hrs therfore 5 days
34
How do you do a lithium dose correction
Current dose/Current plasma level = X dose/Taret plasma level
35
Examples that lower lithium levels?
Preganancy Na supplements***** Hemodialysis Peritoneal dialysis Burns THeophyline Caffeine Acetazolamide Sodium Bicarbonate
36
Examples that increase Lithium levels?
NSAIDs*** Thiazide diuretics*** ACEi/ARBs *** Na loss *** SSRI/SNRI possibly Renal impairment***
37
WHen is there an increased risk of neurotoxicity with Lithium?
When used w/ antipsychotics or carbamazepine
38
What are the 5 main drug classes that have drug interactions with Lithium?
Diuretics NSAIDs ACEi Antipsychotics Antidepressants
39
Common Lithium SEs?
Thirst + increased urination frequency Headaches Sedation Weakness Tremors Skin changes Wt gain (4-6kg in first 2 years) Alopecia
40
Serious Lithium SEs?
hypothyroidism Renal Injury Blood dyscrasias Bradycardia Nephrogenic diabetes insipidus polydipsia polyuria
41
Toxic effects of Lithium at ~1.5mmol/L?
ataxia fine tremors GI disturbances muscle weakness, fatigue
42
Toxic effects of Lithium at 1.5-2.5 mmol/L
sedation lethargy ataxia dysarhtia headhaces increased reflexes hyperthermia course tremors impaired sensorium nystagmus
43
Toxic effects of Lithium at > 2.5mmol/L?
Coarse tremors delirium seizures coma respiratory complications death
44
Lithium Monitoring Plan?
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
What would happen to Lithium if: - Eat lots of slaty foods - Hot yoga - Stopping caffeine - Starting NSAID - 2nd trimester of pregnancy - increased fluid intake
- Eat lots of slaty foods - - Hot yoga + - Stopping caffeine + - Starting NSAID + - 2nd trimester of pregnancy - - increased fluid intake -
46
Valproic Acid Indications?
Seizures BP disorder both acute mania and maintenance
47
Valproic acid elimination?
hepatic; glucoronidation and B-oxidation
48
What Valproic acid metabolite can cause liver toxicity?
4-ene-VP
49
Therapeutic range of VPA?
350-700 micromol/L
50
WHen to take VPA steady state trough level?
3-4 days after intial therapy
51
VP enzyme interactions?
CYP2C9, epoxide hydroxylase, UDPGT
52
Drugs to know that increase VPA?
Macrolides (clarithromycin) ASA Carbapenems LAMOTRIGINE
53
What % should VPA be reduced if lamotrigine on board?
50%
54
VPA AE's?
GI: NVD, constipation CNS: tremors, sedation, ataxia, dizziness wt gain
55
VPA safe in pregnancy?
NO teratogenic
56
VPA monitoring?
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
Lamotrigine good for mainia?
Not great, better for depressive side of BP
58
Lamotirgine indications?
Seizures BP: acute depression, maintenance in BP 1/2
59
Lamotirgine MOA?
Alters signal transduction via voltage NA, reducing glutamate Weak %-HT3 receptor inhibition
60
VPA MOA (general)
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
Why titrate lamotrigine slow?
SJS and TENS risk
62
When must you restart lamotrigine titration?
After 5 days missed doses
63
Common SE of Lamotrigine?
Sedation, headaches, nausea, dizziness
64
Rare SEs of lamotrigine?
SJS aseptic meningitis blood dyscrasias hepatotoxicity
65
Lamotrigne or VPA more sedation?
VPA
66
Lamotrigine monitoring?
hepatic and renal function rash
67
Lamotrigine DIs?
VPA (increase 2x) Carbamazdpine (decrease 30-50%) oral contraception (decrease levels by~50%)
68
Why tapper off of lamotrigine?
may trigger seizure even w/o seizure history
69
Carbamazepine Indications?
Seizures BP: acute mania, maintenance Trigeminal neuralgia
70
Carbamazepine MOA?
blocks vltage NA channels stimulates release of ADH, promoting reabsorption of water blocks NMDA glutamate receptors, modulates aspartate and glutamate release
71
Carbamazepine elimination?
hepatic; CYP3A4, CYP2C8, CYP1A2
72
Unique metabolism of carbamazepine?
autoinduction of its own metabolism
73
Why is carbamazepine not used as much in Bipolar?
b/c interactions, autoinduction
74
Frequency of sampling for carbamazepine?
every 1-2 weeks until stable regimen, steady stte trough after 5 weeks
75
Why titrate slow for carbamazepine
to minimize AEs, sedation and GI can be bad so doses divided can help too
76
Drugs that increase carbamazepine levels?
Macolides Azoles CCBs Grapfruit juice
77
Drugs that decrease carbamazepine levels?
Warfarin DOACs lurasidone (APs) estrogen or progesterone contraceptives Methadone
78
Carbamazepine AEs?
GI: NVC, anorexia, dry mouth CNS: lethargy, dizziness, sedation, hedache, ataxia, blurred vision CV: tachycardia, hypotension hyponatremia blood dyscrasias Rash
79
What postive genetic test increases risk for rash w/ carbamazepine (Asian and Caucasian)
Asian: HLA-B1502 Caucasian: HLA-A3101
80
what WBC warrants d/c of carbamazepine?
<2x10^9/L
81
Carbamazepine CIs?
History of hepatic disease, CVD, blood dyscrasias, bone marrow depression Concurrent use with clozapine
82
Carbamazepine monitoring?
CNS HEENT(ocular exam) CVS(ECG) CBC and electrolytes LFTs Renal function TSH BMD Rash
83
Antipsychotics MOA?
Dopamine blockade
84
atypical or typical APs used more in Bipolar?
atypical
85
are psychosis doses or Bipolar doses higher for APs?
lower for bipolar
86
AP AEs?
EPS hyperprolactinemia, sexual dysfunction metabolic disturbances anticholinergic: sedation antihistaminergic hypotension, dizziness, tachycardia QT prolongation seizures
87
Acute mania 1st line therapies:
Mono: Lithium, quetiapine, VPA, aripiprazole, paliperidone (>6mg), risperidone Combo: Lithium or VPA + quetiapine, risperidone, asenapine
88
When is VPA reccomended over Lithium
more episodes
89
Bipolar 1 depression 1st line?
Quetiapine, lurasidone + Lithium or VPA, Lithium, lamotrigine mono or adjunct
90
Bipolar 1 maintenance 1st line?
Lithium Quetiapine VPA Lamotrigine Asenapine Aripiprazole Lithium/VPA + quetiapine or aripiprazole
91
Mixed episodes recommended pharmacotherapy?
d/c antidepressants monotherapy of atypical AP or combo w/ Lithium or VPA
92
Treatment in pregnancy?
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
Which med has best evidence for suicide prevention in Bipolar?
Lithium; but overdose is fatal so dispensing may need to be altered

PHAR 358 M1 (2 decks)

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