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Bipolar Flashcards

1
Q

Bipolar I

A

One or more manic or mixed episodes

Most also have some depression

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2
Q

Bipolar II

A

One or more depressive episodes + at least one hypomanic episode

Often misdiagnosed as MDD

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3
Q

Cyclothymic disorder

A

Several periods of hypomania and mild depression but do not meet criteria for mania, major depressive

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4
Q

Rapid cycling

A

At least 4 episodes of mania, hypomania, or depression in 1 year with 2 months between episodes

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5
Q

Bipolar I treatment of choice

A

Lithium

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6
Q

Lithium onset

A

Antimania: 1-2 weeks. May need adjunctive benzo or antipsychotic to control symptoms

Antidepressant effect: 6-8 weeks

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7
Q

Lithium monitoring labs

A

Baseline: CBC, electrolytes, renal function, thyroid function, UA, ECG, pregnancy test

every 6-12 months: Renal function, thyroid function, UA

Order serum concentration 12 hours after last dose, 5-6 days after initiation

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8
Q

Lithium serum concentration for acute mania

A

0.8-1.2

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9
Q

Lithium serum concentration for maintenance

A

0.6-1.0

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10
Q

Lithium toxicity

A

Lethargy
Coarse tremor
Confusion
Seizures
Coma
Death

Treatment of choice if severe: hemodialysis

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11
Q

Intervention if rash, psoriasis from lithium

A

D/C drug (temporary or permanent)

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12
Q

Intervention of tremor from lithium

A

Decrease dose
Add BB

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13
Q

Intervention if CNS toxicity from lithium

A

Reduce dose

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14
Q

Intervention if GI upset from lithium

A

Reduce dose
Try ER
Split doses

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15
Q

Intervention if hypothyroid from lithium

A

Levothyroxine
D/C lithium if necessary

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16
Q

Intervention if polydipsia or polyuria from lithium

A

Reduce dose
Manage fluid intake
Change to single bedtime dose

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17
Q

Intervention if interstitial fibrosis or glomerulosclerosis from lithium

A

Lower dose to achieve lowest effective concentration

Avoid dehydration

18
Q

Lithium and pregnancy

A

Avoid during first trimester

19
Q

Agents to avoid with lithium

A

Thiazides
Furosemide
NSAIDs
ACE-Is

All increase lithium plasma concentrations and could cause toxicity

20
Q

Theophylline and lithium

A

lowers lithium concentration

21
Q

Neuromuscular blockers and lithium

A

lithium may prolong neuromuscular blocker effect

22
Q

Lithium and carbamazepine

A

Increase CNS toxicity
Not contraindication, but not commonly combined in practice

23
Q

Lithium and neuroleptics

A

Lithium may potentiate EPS

24
Q

Lithium and the thyroid

A

Lithium decreases synthesis and release of thyroid hormone, thus causing hypothyroidism

25
Q

Dehydration, salt restriction, extrarenal salt loss on lithium

A

Increases sodium reabsorption which increases lithium plasma concentration

26
Q

Decreased renal function and lithium

A

Decreased GFR and increased creatinine/BUN will increase lithium plasma concentration

27
Q

Aging and lithium

A

Aging decreases GFR and increases sensitivity to ADRs. Will need to decrease lithium requirements.

28
Q

Divalproex/Valproate for bipolar

A

As effective as lithium

Better for rapid cycling than depressive episodes

29
Q

Divalproex/valproate BBW

A

Hepatotoxicity (LFTs monitored routinely)

Mitochondrial disease (increases risk for liver failure)

Fetal risk

Pancreatitis

30
Q

Divalproex/valproate serum concentration

A

50-125 but usually target level at when achieve clinical response

> 80: neurotoxicity, sedation, hair loss, thrombocytopenia

31
Q

Divalproex enteric coated to ER dosage form

A

Increase dose 8-20% due to less bioavailability with ER form

32
Q

Carbamazepine for bipolar

A

Only for acute mania and maintenance therapy

Strong inducer and autoinducer, so can take time to come to steady state

33
Q

Lamotrigine in bipolar

A

Approved for maintenance therapy. Best at preventing depressive episodes compared to manic episodes

Not effective in acute phase due to long titration

34
Q

Missed lamotrigine doses

A

If miss >3-5 half lives (5 days), reinitiate from starting dose

35
Q

Lamotrigine + valproic acid

A

increased risk for SJS rash

36
Q

Lamotrigine rare ADRs

A

SJS
Aseptic meningitis
Hemophagocytic lymphohistiocytosis (HLH)

37
Q

SGAs for acute bipolar treatment

A

All FDA approval except brexpiprazole, clozapine, iloperidone, lumateperone, lurasidone

First line agents for acute mania:
Aripiprazole
Asenapine
Cariprazine
Paliperidone
Quetiapine
Risperidone

38
Q

SGAs for bipolar depression

A

Cariprazine
Quetiapine
Lumateperone
Lurasidone
Olanzapine + fluoxetine

39
Q

SGA for bipolar maintenance

A

Risperal Consta
Abilify Maintena
Olanzapine
Quetiapine

40
Q

Antidepressants and Bipolar

A

Avoid monotherapy as it can switch to manic phase (highest risk with TCA and SNRI)

Avoid if symptoms of mania present

41
Q

Type II Bipolar treatment

A

First-line agent = lithium, but remember takes 6-8 weeks for depressive symptom resolution

Acute phase: Quetiapine, lurasidone

Maintenance: lamotrigine

Olanzapine + fluoxetine

BCPS (40 decks)

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