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Pharmacology III > Bipolar > Flashcards

Bipolar Flashcards

1
Q

When do symptoms usually occur in bipolar disorder?

A

Late adolescence or early adult hood
Median age at onset is 20 y/o
However, some may exhibit first sx during childhood or later in life

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2
Q

What is the frequency of episodes of bipolar disorder correlated with?

A

Increases with Age

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3
Q

What is bipolar I disorder?

A

Manic episodes recur in >90%
Spend 3x as long in depressed and manic states
Exhibit higher rate of reckless activity, dristractibility, agitated activity, irritable mood, and increased self-esteem

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4
Q

What is involved with Bipolar II disorder?

A 
Higher lifetime prevalence of depressive episodes
High prevalence of Fhx
Higher co-morbidity w/ anxiety disorders
Shorter inter-episode intervals
Faster onset
More chronic course of dz
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5
Q

What are the two most common co-morbid anxiety disorders associated w/ bipolar?

A

Panic Disorder

Obsessive-Compulsive disorder

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6
Q

What are the monamines that are involved with regulation of mood?

A

Norepinephrine
Seratonine
Dopamine

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7
Q

What does dysregulation of the monoamines (NE, 5-HT, DA) lead to?

A

Depression or mania

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8
Q

What other neurobiology is involved with mood disorders?

A

Cholinergic system
GABA
Glutamate
Glucocorticoids

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9
Q

What plays a major role in pathogenesis and pathophysiology of mood disordrs?

A

Neuroplastic changes in the brain

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10
Q

What are the bipolar treatment challenges?

A 
Acute manic episodes
Acute depressive episodes
Acute mixed episodes (manic and depressive together)
Psychotic freatures
Rapid cycling (>4 acute episodes/year)
Co-morbid substance abuse
Hypomanic episodes
Seasonal episodes
Chronic management and prophylaxis
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11
Q

What are the reasons for medication non-adherence in bipolar disorder?

A 
Not convinced that meds work
Intolerant to side effects
Do not want to take antipsychiatric meds
Medication cost
Inconvenience
Lack of insight
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12
Q

When do acute manic episodes start and who do they occur in?

A

Onset typically before 30 and in men and women equally

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13
Q

What is the course for acute manic episodes?

A
  • Begin suddently
  • insomnia and irritability are prominent
  • Rapid escalation of sx over a few days
  • Episodes last a few days to months.
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14
Q

What are the common sx of manic episodes?

A
  • Lasting period of abnormal behavior
  • Increased energy, activity, and restlessness
  • Excessive high, overly good, and restlessness
  • Extreme irritability
  • Racing thoughts/talking fast, jumping from one idea to the next.
  • Distracted not able to concentrate
  • Needs little sleep
  • Unrealistic beliefs in ones ability and powers
  • Poor judgement
  • Spending sprees
  • Increased sex drive
  • Religious preoccupation
  • Provocative, intrusive, or aggressive behavior
  • Denial that anything is wrong
  • Abuse of drugs, particularly cocaine, ETOH, and sleeping meds.
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15
Q

What are the hyperactive behavior & mood changes?

A

Insomnia, irritability, loud, distractable, impulsive, pressured speech, increased motor activity, intrusive, expansive, intense, labile, hypersexual, manipulative, aggressive

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16
Q

What is rapid speech and switching among multiple ideas/topics?

A

Flight of Ideas

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17
Q

What is a vague relationship between thoughts?

A

Loose associations

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18
Q

What is involved in the neurobiology of mania?

A

NE- Relative excess
5-HT- relative deficiency
DA- relative excess

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19
Q

What is involved with stage 1 of mania (Hypomania)?

A
  • Euphoria
  • Labile affect (irritability, happy then agry)
  • Grandiosity
  • Overconfidence
  • Excessive risk-taking
  • Racing thoughts
  • Increase psychomotor acvitivy (energy, activity, restlessness)
  • Increase in rate & amount of speech
  • Decreased need for sleep
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20
Q

What is involved in mania stage 2?

A 
Increased irritability
Hostility
Anger
Delusions
Congnitive disorganization
Dysphoria (feeling of extreme discomfort & unrest)
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21
Q

What is involved with mania stage 3?

A 
Panic
Terror
Bizare behaviors
Frenzied activity
Hallucinations
Progression from disorganized though patterns to incoherence and disorientation
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22
Q

What are the goals of tx of acute mania?

A

Stabalize- obtain rapid control of agitation, aggression, impulsiveness, insomnia
Achieve remission- return to baseline level of functioning, no functional impairment

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23
Q

What is the non-pharmacologic tx of acute mania?

A

Reduce over stimulation (calm quiet environment)

Reduce potential for risky behaviors (safe, highly structured environment)

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24
Q

What are the pharmacotherapy tx of acute mania?

A

Antimanic agents or mood stabilizers
Antisychotics (1st and 2nd gen)
Benzodiazepines (PRN and/or short-term for agitation, anxiety, insomnia)
Antidepressants (discontinue)

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25
Q

What are the 2nd generation antipsychotics used to treat acute mania that are FDA approved?

A 
Aripiprazole
Olanzapine
Quetiapine
Risperidone
Ziprasidone
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26
Q

What are the 1st generation antipsychotics used to treat acute mania?

A

Haloperidol

Chlorpromazine

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27
Q

Do you need to discontinue antidepressants being used to treat acute mania?

A

Yes
Antidepressants may induce mania or hypomania, increase frequency of recurrence of acute episodes, promote tenancy for course of illness to become continuous.

MUST TAPER

28
Q

How should treatments be individualized for bipolar disorder?

A

Treatment should be individualized: clinical presentation, severity, and frequency of episodes vary widely among patients.

29
Q

What are the three most commonly used drugs for bipolar disorder tx?

A

Three primary drugs used are lithium, carbamazapine, and valproic acid.

30
Q

Lithium (Eskalith®, Lithobid®)- Indications

A

Acute manic episodes
Prophylaxis of affective disorders
Acute depressive episodes

Other psychiatric disorders 
Schizoaffective disorder/Schizophrenia
Aggressive/violent behaviors
Impulse control disorders
Self-injurious behavior
Mania secondary to brain injury
31
Q

What is involved with the pre-lithium work up?

A 
CBC w/ diff
Chem profile (Electrolytes, creatinine, BUN)
Thyroid function tests
UA
FBS
ECG
VItals
Serum pregnancy test
32
Q

Lithium (Eskalith®, Lithobid®)- Acute side effects

A 
usually transient but may become chronic
N,V,D
muscle weakness
polyuria, polydypsia
fine hand tremor
edema
33
Q

What are the sx of acute toxicity of lithium?

A

persistent vomiting impaired renal function
diarrhea lethargy/confusion
COARSE HAND TREMOR somnolence
dysarthria seizures
muscle weakness coma
hyperactive deep tendon reflexes (DTR)
vertigo

34
Q

What is the management of lithium toxicity?

A

-D/C lithium
-Obtain lithium serum concentrations, renal panel, vitals, & EKG
-Supportive Care
-Maintain fluid and electrolyte balance
-Gastric lavage if within 1 hour
No charcoal, doesn’t bind lithium
-Whole bowel irrigation with delayed release preparations
-Hemodialysis

35
Q

Lithium (Eskalith®, Lithobid®)- LChronic effects

A 
Weight gain
Hypothyroidism (monitor function)
Diabetes insipidus (tx with amiloride)
Leukocytosis
Rash (acne, psoriasis exacerbation)
ECG changes (T wave flattening, QRS inversion
Nephrotoxicity
36
Q

Lithium (Eskalith®, Lithobid®)- routine therapeutic monitoring

A
  • -Serum lithium concentration obtained 5-7 days after initiation of therapy and with every dose change, then every 3 mo. for 6 mo. and every 6 mo. thereafter.
  • -BUN, Scr, electrolytes - every 3 months for 6 mo. and every 6 mo. thereafter.
  • -Thyroid function test - every 3 months for 6 mo. and every 6 mo. thereafter.
  • -Urinalysis
  • -CBC - Q12 mo.
  • -Monitor for signs of toxicity; pregnancy test in females (Cat. D)
37
Q

Lithium (Eskalith®, Lithobid®)- Drug interactions

A
  • Thiazide diuretics
  • Osmotic diuretics, acetazolamide
  • Aminophylline, Theophylline
  • SSRIs, Fluoxetine
  • Haloperidol
  • clozapine
  • Carbamazepine
  • Metronidazole - abx
  • ACE Inhibitors
  • NSAIDS
  • Calcium channel blockers, verapamil
38
Q

What are the advantages of lithium therapy?

A
  • Will control a manic patient without a “drugged effect”
  • Will normalize mood
  • Very good prophylactically to decrease mood swings
  • Relapses, when they occur, are less severe and usually shorter in duration
  • Plasma concentration monitoring allows careful titration to therapeutic levels
  • Low drug cost
39
Q

What are the disadvantages of lithium therapy?

A

-Narrow range of therapeutic blood concentrations, requires close monitoring to prevent toxicity.
-Patient compliance and understanding of the warning signs of toxicity is important.
-Lag period before therapeutic effect in manic patients.
Prophylactic effect may take 6 months to 1 year to maximize.
-Rapid cyclers are poor responders.
-Expense of blood tests

40
Q

Carbamazepine (Tegretol®)- indications

A

Acute manic episodes
Usually in patients who are treatment resistant, rapid cyclers, lithium intolerant.
Prophylaxis of affective disorders

Other psychiatric disorders
Impulse control disorders
Schizoaffective disorder/schizophrenia (not first line)
Neuropsychiatric disorders in the mentally retarded/developmentally disabled.
Trigeminal neuralgia
Mania secondary to head injury
Aggressive and violent behaviors/rage reactions

41
Q

Carbamazepine (Tegretol®)- adverse effects

A

Neurologic- sedation, ataxia, diplopia, dizziness, fatigue, headache, nystagmus, tingling, tremor
Dermatologic- rash, steven johnson syndrome (Most concerning)
Hematologic- transient leukopenia, THROMBOCYTOPENIA (most common), eisinophilia, aplastic anemia, and agranulocytosis
GI- N/V/D
Other- SIADH, slowed cardiac conduction, hepatotoxic, teratogen

42
Q

What is the most concerning ADR of carbamazepine?

A

Steven Johnson’s Syndrome

43
Q

Is carbamazepine an autoinducer?

A

Yes

44
Q

Carbamazepine (Tegretol®)- routine monitoring

A

-Every 2 weeks for 2 months, then every 3 to 6 months
-Chemistry profile
-CBC w/diff. and platelets (to check for SE)
-Liver profile (check for SE)
-Urinalysis
-Carbamazapine blood levels for:
initial stabilization of a pt
therapy failure, inadequate response, worsening of symptoms
complex drug regimens—dose related side effects, drug interactions
Compliance issues differing plasma levels with stable prescribed doses

45
Q

Carbamazepine (Tegretol®)- drug interactions

A

Carbamazepine is a potent liver enzyme inducer which can decrease levels of other drugs:

  • Antipsychotics
  • Tricyclic antidepressants
  • Theophylline
  • Steroids
  • Warfarin (narrow therapuetic so you risk worsening condition)
  • Chloramphenicol
  • Isoniazid
  • Thyroid Hormones (narrow therapuetic so you risk worsening condition)
  • Methadone
46
Q

What are the drugs that can increase carbamazepine concentrations?
Hint- P450 inhibitors

A 
Erythromycin
Fluoxetine
Theophylline
Cimetidine
Verapamil
Diltiazem
Propoxyphyne (Darvon)
47
Q

What are the drugs that can decreased carbamazepine concentrations?
Hint- P450 inducers

A

Phenobarbital
Phenytoin
Primidone
Theophylline

48
Q

Valproic Acid, Divalproex Sodium (Depakene® and Depakote®)- Indications

A 
Bipolar affective disorder (esp. rapid cyclers and mixed states)
Aggression and impulse control disorder
Mania secondary to head injury
Bulimia
Schizoaffective disorder/schizophrenia
49
Q

What is the gold standard for treating bipolar disorder?

A

Lithium

50
Q

Valproic Acid, Divalproex Sodium (Depakene® and Depakote®)- Adverse Effects

A 
--Gastrointestinal
N,V, D, stomach cramps
Constipation
Anorexia, wt. loss/gain
Hemorrhagic pancreatitis
--Neurologic
sedation/drowsiness
Tremor
Nystagmus/diplopia
---Endocrine
Breast enlargement, galactorrhea, irregular menses
51
Q

What drugs can decrease valproic acid concentrations?

A

Phenobarbital
Phenytoin
Primidone
Carbamazepine

52
Q

What drug concentrations are increased with valproic acid?

A

Phenytoin

Phenobarbital

53
Q

When combined what have clonazepam and valproate causes?

A

Absence seizures

54
Q

What is the presentation of bipolar II with major depression episodes?

A 
Irritability
Mood lability
Racing thoughts
Increased sexuality
Distractability
Increased risk for suicide
55
Q

What are the goal treatments for bipolar depression

A

Remission of sx
Return to normal functioning
Avoid precipitation of mania or hypomania

56
Q

What are the non-pharmacologic tx goals of bipolar depression?

A

Interpersonal psychotherapy
Cognitive behavioral therapy
Group psychotherapy

57
Q

What are the FDA approved drugs used to tx bipolar depression?

A

Olanzapine + fluoxetine

Quetiapine

58
Q

When can mood stabilizers be used for bipolar depression?

A 
May be used as montherapy or as add-on therapy for BP depression
Lithium
Lamotrigine
Valproate
Carbamazepine
59
Q

What antipsychotics do you want to use for a patient with bipolar depression?

A

Olanzapine

Quetiapine

60
Q

Should antidepressants be used to tx bipolar depression?

A

None have been approved. The only one is FLX with olanzapine

61
Q

What are the most commonly used agents for bipolar I?

A 
Lithium
Lamotrigine
Quetiapine
Olanzapine/fluoxetine
Valproate
Carbamazepine
62
Q

What are the most commonly used agents for bipolar II?

A 
Lithium
Lamotragine
Carbamazepine
Valproate
Antidepressants
63
Q

How is first line tx for bipolar depression selected?

A 
Sx profile
Course of illness
Prior hx of response
Family hx of response
Tolerability issues
Optimize first line, if no response augment/switch to another first line. If no response consider second-line tx, if inadequate response consider combos
64
Q

What are the primary goals after resolution of acute episodes of bipolar?

A 
Prevent re-occurrence
Extend intervals b/w episodes
Decrease severity of episodes
Maximize patient functioning 
Minimize sub threshold sx
Minimize med ADRs
Prevent suicide
Identify prodromal sx
65
Q

How do you treat rapid cycling?

A

Assess and tx medical condition
Discontinue antidepressent
Agents of choice- valproate, lithium, lamotrigine, 2nd gen antipsychotic, ECT

66
Q

What are the therapies for bipolar?

A 
Medication combinations
ECT
Sleep deprivation
Thyroid supplementation
Vagal nerve stimulation
Psychotherapy
Homeopathy
Vitamin supplements
Herbs

Pharmacology III (19 decks)

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