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662 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

Four valproic acid products?

A
  • Valproic Acid (Depakene)
  • Sodium Valproate (Dapakene Syrup)
  • Divalproex Sodium Delayed Release (Depakote, BID)
  • Divalproex Sodium Extended release (Once daily, less bioavailable)
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2
Q

Efficacy of VPA

A
  • 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
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3
Q

Pharmacokinetics of VPA

Half-life? How many Days to reach steady state

Metabolism what pts might be influenced by this?

Proteins Binding?

A
  • 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
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4
Q

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

A
  • 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

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5
Q

VPA monitoring?
What guidelines do you usually follow
When is the level taken?

A

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?

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6
Q

VPA common side effects?

Wt gain

A
  • Common, GI switching to divalproex can help
  • Sedation, tremor, wt gain
    Alopecia
  • Thrombocytopenia
  • Hepatic Dysfunction
  • Polycystic Ovarian Syndrome
  • Pancreatitis
  • Hyperammonemia- Acut mental status - Check
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7
Q

Monitoring with VPA

A

CBC- monthly for 1st 2 months
LFTs same thing
Plasma drug levels
Pregnancy test

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8
Q

VPA drug interactions?

A
  • Inhibitor of lamotrigine metabolism, most common

- Watch with warfarin and Aspirin

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9
Q

Carbamazepine

A
  • Structurally related to TCA
  • Antimanic and prophylactic effects can be compared to Lithium and VPA
  • Effective for rapid cyclers and mixed episodes
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10
Q

Carbamazepine

Metabolism

A
  • In liver
  • Induces its own metabolism
  • initial t 1/2 25-65 after auto induction t 1/2 12-15
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11
Q

Carbamazepine dosing

Acute mania?

A

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)
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12
Q

Carbamazepine Therapeutic Monitoring

A

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
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13
Q

Carbamazepine SEs

A
  • Drowsiness, Fatigue, Ataxia, Blurred vision, Diplopia
  • Leukopenia, Agranularcytosis (infections not getting better)
  • Steven johnson syndrome (HLA-b-1502 gene)
  • Hyponatriumia
  • Aplatic anemia
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14
Q

Carbamazepine Drug interactions

A
  • Inducer
    • P450
  • contraceptives is the big one
  • Dont want to give Carbamazepine and Clozapine together because this will increase the risk of agranularcytosis
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15
Q

Lamotrigine (Lamictal)

A
  • 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.
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16
Q

Lamotrigine DOsing?

A

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

17
Q

Other antimanic treatments?

A
  • 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
18
Q

Epidemiology fro Bipolar?

A

Onset is 18-44 years (mean is 20)

- Significant genetic risks

19
Q

Mania signs and Symptoms?

FastDig

A 
Distractibility 
Insomnia
Grandiosity
Flight of ideas
Activity 
Speech 
Thoughtlessness
20
Q

Severe mania signs and symptoms

A
  • Often resembles paranoid schizophrenia
  • Bizarre behavior
  • Hallucinations
  • Delusions
  • 2/3 of pts will have psychotic symptoms
21
Q

Course of Bipolar illness

A
  • 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)
22
Q

Classifying Manic Bipolar

A
  • Symptoms 1 wk
  • grandiosity
  • decreased sleep
  • Pressured speech
  • Racing thoughts
  • Distractibility
  • Increase energy
  • High risk behavior
    Stopped at this!
23
Q

First trimester exposure to what causes birth defects

A

Li, VPA, CBZ

24
Q

What are alternative options for pregnancy

A

High potency antipsychotics
Haloperidol
BDZ- Cleft palate
ECT- is an option

25
Q

What drugs can you breast feed with?

A

VPA and CBZ

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