Bipolar 3: Tx

Question 1

Lithium carbonate uses (5)

Answer 1

1. Bipolar Disorder
2. Schizoaffective Disorder
3. Augmentation in Major Depressive Disorder
4. Impulse control disorders
5. Aggression: Mental retardation, Personality disorders

Question 2

Lithium dosing

Answer 2

• Goal: obtain 0.6-1.4 mEq/L (tiny Therapeutic window)
• 300 mg bid or extended release qd

(maintenance serum level every three months)

Question 3

Lithium is successful and effective in treating bipolar disorder in ____% of cases

Answer 3

70

Question 4

Lithium: side effects (8)

Answer 4

1. Thirst, polyuria, weight gain, edema (its a salt)
2. Hypothyroidism
3. Elevated calcium & parathyroid hormone
4. Nonspecific T wave changes
5. Worsen acne or psoriasis
6. Leukocytosis
7. PD-like symptoms
8. Cognitive slowing

(May reduce the risk of melanoma)

Question 5

Lithium is similar to ______ (element). Which conditionis associated with it’s use?

Answer 5

• Iodine
• Hypothyroidism

Question 6

How do you monitor hypothyroidism while treating bipolar disorder with lithium?

Answer 6

Monitor at Baseline and every 6 to 12 months

Question 7

Lithium is excreted via ________

Answer 7

kidneys are reabsorbed in the proximal tubules with Na and water

Question 8

Hyponatremia will cause _____ in a patient who is treated with lithium.

Answer 8

lithium toxicity

(the kidneys will compensate by reabsorbing more sodium than normal in the proximal tubules, lithium is re-absorbed with it)

Question 9

Long term use of lithium: renal side effect

Answer 9

Reduced glomerular filtration rate

(renal function should be assessed at baseline and every 6 to 12 months or after)

Question 10

_____ should be avoided in patients taking lithium

Answer 10

Sodium depleting diuretics (thiazides)

Question 11

Lithium toxicity is a medical emergency and is a blood level of ______

Answer 11

3 mM

Question 12

Lithium toxicity symptoms (9)

Answer 12

1. neuromuscular irritability or flaccidity
2. dysarthria
3. tremor
4. ataxia
5. renal failure
6. confusion
7. hallucinations
8. seizures
9. stupor

(Can cause permanent cerebellar ataxia, death)

Question 13

Lithium levels are at a peak _____ (time) after absorption

Answer 13

2 hours

(rapidly absorbed from the gut)

Question 14

Lithium half life (manic and euthymic patients)

Answer 14

• Manic: 8-12 hours
• Euthymic: 18-36 hours

Question 15

Lithium metabolism (3)

Answer 15

1. Kidneys (found in all bodily fluids)
2. No protein-bound (easily crosses BBB)
3. No metabolites

Question 16

Treatment for lithium toxicity

Answer 16

Dialysis

Question 17

Lithium contraindications

Answer 17

1. Renal disease
2. MI (for 2 weeks)
3. Myasthenia gravis
4. Diabetes, ulcerative colitis, psoriasis
5. Senile cataracts

Question 18

Lithium mechanism of action

Answer 18

Unknown but may be correlated with gene expression for growth factors and neuronal plasticity

(Inositol Depletion Hypothesis & Regulation of the Wnt and Glycogen Synthase Kinase 3 beta. GSK 3B is an important enzyme in pathways including the Wnt signaling cascade)

Question 19

Lithium may cause ______ if use during the first trimester of pregnancy.

Answer 19

Ebstein’s anomaly

(heart develops in the first 6 weeks of gestation; you have to weigh the risks, the patient may be suicidal. Baby will also have effects from untreated bipolar- glucocorticoids, etc)

Question 20

Valproate uses

Answer 20

1. Seizures
2. Migraine headache
3. Bipolar disorder

Question 21

Valproate is digested through the stomach and highly protein-bound. Half life _____

Answer 21

8-17 hours

(highly protein bound; rapidly reabsorbed)

Question 22

How often are valproate levels checked

Answer 22

Monthly until stable than every 6 months

(plasma levels 50 to 125 mcg/ml = response)

Question 23

Valproate side effects

Answer 23

1. Vomiting
2. Poor Appetite
3. Liver Toxicity (Hepatic transaminase elevation)
4. Retain fat (Weight gain)
5. Tremor
6. Sedation

(mnemonic: VALRT - VALpRoaTe)

(coma and death from overdose)

Question 24

Valproate black box warning:

Answer 24

1. Hepatotoxicity
2. Pancreatitis
3. Teratogenicity (neural tube defects; mental retardation)

Question 25

Carbamazepine serum levels that correlate with effectiveness

Answer 25

8-12 mcg/ml

Question 26

Carbamazepine side effects:

Answer 26

1. Rash 2. Leukopenia 3. impaired coordination, drowsiness, slurred speech, ataxia

Question 27

Carbamazepine black box warning

Answer 27

1. Teratogenicity 2. aplastic anemia and agranulocytosis 3. Toxic epidermal necrolysis (SJS when \>30% of the skin is effected)

Question 28

What is an advantage to Lamotrigine that you don't find with other bipolar treatments?

Answer 28

You don't need to check the blood levels

Question 29

Lamotrigine uses

Answer 29

Maintenance of bipolar treatment

Question 30

Lamotrigine MOA

Answer 30

Blocks Na⁺ channel → inhibits release of presynaptic glutamate aspartate and GABA (possibly; mechanism unclear)

Question 31

Antidepressants in bipolar depression may have the following negative effects _____ (3).

Answer 31

1. Depression to Mania 2. Increase cycle frequency 3. Convert condition to more malignant form

Question 32

Lamotrigine: pharmacokinetics

Answer 32

60% protein bound

Question 33

Lamotrogine side effects

Answer 33

1. possible rash (slow titration reduces this risk) 2. Steven-Johnson syndrome 3. Teratogenicity: cleft lip ## Footnote ***_(Fewest side effects of all)_***

Question 34

Nonpharmacologic treatment for bipolar

Answer 34

1. Psychotherapy 2. Light therapy for depression (risk of mania and hypomania) 3. Electroconvulsive therapy for Mania and depression

Question 35

Physician-patient interaction with manic patients : difficulties

Answer 35

1. Pressured speech→ difficult to interview 2. They think that they are fine 3. Physician may feel angry fear or frustration

Question 36

How can you establish a common ground with a patient in a manic episode?

Answer 36

Psychophysiological symptoms (i.e. "You haven't sleep in 3 days, we need to do something about this." They are less likely to respond to comments on their behavior)

Question 37

***_General_*** First-line maintenance treatment: bipolar 1

Answer 37

1. Mood stabilizing medication 2. Reassess need for antipsychotic and antidepressants (Discontinue antipsychotic (unless they have persistent psychosis))

Question 38

Why is it best to ***_prevent_*** episodes of bipolar disorder?

Answer 38

More than 4 episodes increases the risk of dementia, diabetes, heart disease

Question 39

Second-line maintenance treatment of bipolar disorder

Answer 39

1. ECT (once per month) 2. Individual or group psychotherapy

Question 40

General principles of bipolar disorder care (4)

Answer 40

1. To the illness, not the episode 2. Educate on destabilizing factors 3. Use regimine they can stick to 4. Acute episode drug needs are often different from maintenance needs

Question 41

Destabilizing factors for bipolar disorder

Answer 41

1. Shift-work 2. Not sleeping 3. Substance use issues

Question 42

Why is compliance difficult for patients with bipolar disorder?

Answer 42

1. Side effects 2. They miss the high of mania (creativity and productivity) 3. Dislike mood control by meds 4. Denial of chronic illness

Question 43

Concomitant use of _____ have a potential to rise a lithium levels.

Answer 43

NSAIDs (possibly through effect on renal prostaglandin synthesis or decreased )

Question 44

Oxcarbamazepine (trileptal) is also used to treat bipolar. Side effects are similar to carbamazepine but less risk of \_\_\_\_\_

Answer 44

anemia and agranulocytosis

Question 45

Which two drugs are not effective as mood stabilizers but may be helpful for anxiety in bipolar patients?

Answer 45

1. Gabapentin (Neurontin) 2. Regabalin (Lyrica): (picmonic: The gabakusa penguin disguises itself as a Goose to infiltrate Caesars Zoo & punish Caesar for keeping animals captive)

Question 46

Which drug is not effective as a mood stabilizer but is used in PTSD and headaches?

Answer 46

Topiramate (Weight loss is a common side effect)

Question 47

What do you do w/a patient who has parkinson's disease and psychosis?

Answer 47

if you can't adjust parkinson's med → use loose-binding D2 antagonist (Rx goes to all DA receptors, we can't pecifically target them)