Bipolar Flashcards
Four valproic acid products?
- Valproic Acid (Depakene)
- Sodium Valproate (Dapakene Syrup)
- Divalproex Sodium Delayed Release (Depakote, BID)
- Divalproex Sodium Extended release (Once daily, less bioavailable)
Efficacy of VPA
- As effective as lithium in pure mania
- May be more effective in rapid cycling and mixed mania than lithium
- VPA is least effective in treatment of acute depression
Pharmacokinetics of VPA
Half-life? How many Days to reach steady state
Metabolism what pts might be influenced by this?
Proteins Binding?
- T 1/2 = 16 hrs. 3-4 days to reach Steady-steady, important for duration
- Metabolized in the liver, liver failure pts watch for hepatotoxicity
- 90% bound to albumin
VPA Dosing
Titration Method
- Start at ____ - 1000 mg/d in divided doses
Increase by _____ -_____ every 2-3 days up to 1000 - _______ (max?)
Why would this method not be beneficial for some patients?
Loading Dose
- 20 mg/kg in divided doses
- Typically used in?
Dosing can be given all at? When pt is stable
- Start at 500 - 1000 mg/d
- Increase by 250-500 mg/d every 2-3 days, up to 1000- 3000 mg/d
- Max 60 mg/kg
- This method is not for patients with acute agitation due to the slow efficacy
- Loading dose used in patients that are acutely agitated and severe mania patients
Dosing can be given all at bedtime if the patient is stable
VPA monitoring?
What guidelines do you usually follow
When is the level taken?
No therapeutic drug concentration has been established for VPA in mania
- Usually follow anticonvulsant therapeutic range (50-125 mcg/mL)
- Level is taken 12 hours after last dose.
Therapeutic Range is wide- toxic symptoms- sedation
Troph levels?
VPA common side effects?
Wt gain
- Common, GI switching to divalproex can help
- Sedation, tremor, wt gain
Alopecia - Thrombocytopenia
- Hepatic Dysfunction
- Polycystic Ovarian Syndrome
- Pancreatitis
- Hyperammonemia- Acut mental status - Check
Monitoring with VPA
CBC- monthly for 1st 2 months
LFTs same thing
Plasma drug levels
Pregnancy test
VPA drug interactions?
- Inhibitor of lamotrigine metabolism, most common
- Watch with warfarin and Aspirin
Carbamazepine
- Structurally related to TCA
- Antimanic and prophylactic effects can be compared to Lithium and VPA
- Effective for rapid cyclers and mixed episodes
Carbamazepine
Metabolism
- In liver
- Induces its own metabolism
- initial t 1/2 25-65 after auto induction t 1/2 12-15
Carbamazepine dosing
Acute mania?
Initial 400 mg/d in divided doses w/ meals
- Increased by 200 every 2 - 4 days
- Rapid titration may cause nausea, vomiting, mild neurotoxicity (Drowsiness, dizziness, ataxia, clumsiness, diplopia)
Carbamazepine Therapeutic Monitoring
Target levels 5-12 mcg/ml
- higher levels may be desired in acute mania (10-14)
- Get levels 12 hours out of dose
- Drug levels should be drawn every 1-2 weeks during the 1st 2 months the every 3-6 weeks
- Levels can drop within 3 wks due to auto inductions
Carbamazepine SEs
- Drowsiness, Fatigue, Ataxia, Blurred vision, Diplopia
- Leukopenia, Agranularcytosis (infections not getting better)
- Steven johnson syndrome (HLA-b-1502 gene)
- Hyponatriumia
- Aplatic anemia
Carbamazepine Drug interactions
- Inducer
- P450
- contraceptives is the big one
- Dont want to give Carbamazepine and Clozapine together because this will increase the risk of agranularcytosis
Lamotrigine (Lamictal)
- FDA approved for maintenance treatment of Bipolar Disorder
- Effective in treatment of bipolar depression
- AEs- Rash, can lead to steven-johnsons
Not good at treating acute manic episode, it takes a couple weeks to take effect.
Lamotrigine DOsing?
1-2 25. If taking carbamazepine start a 50 then 100 and
3-4- 50. Increase by 100 at 5 wks
5- 100
6- 200
7- 200
Other antimanic treatments?
- Gabapentin - Negative results for bipolar disorder - has no DIs
- Oxcarbazepine
- Topiramate- Wt loss, Slows cognition
- Zonisamide- Sulfa allergy
- Levetiracetam - Lots of mood changed, cleared regally, not good for patient with psychiatric problems
Epidemiology fro Bipolar?
Onset is 18-44 years (mean is 20)
- Significant genetic risks
Mania signs and Symptoms?
FastDig
Distractibility Insomnia Grandiosity Flight of ideas Activity Speech Thoughtlessness
Severe mania signs and symptoms
- Often resembles paranoid schizophrenia
- Bizarre behavior
- Hallucinations
- Delusions
- 2/3 of pts will have psychotic symptoms
Course of Bipolar illness
- Average age of first manic episode is mid 20s
- Most patients will have more then one in their life
- 80% or more will have > 4 episodes
- Typically a period of normal mood in between
- Untreated episodes last several months (3-6)
Classifying Manic Bipolar
- Symptoms 1 wk
- grandiosity
- decreased sleep
- Pressured speech
- Racing thoughts
- Distractibility
- Increase energy
- High risk behavior
Stopped at this!
First trimester exposure to what causes birth defects
Li, VPA, CBZ
What are alternative options for pregnancy
High potency antipsychotics
Haloperidol
BDZ- Cleft palate
ECT- is an option
What drugs can you breast feed with?
VPA and CBZ
