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Clinical 2.0 winter > Bipolar affective disorder > Flashcards

Bipolar affective disorder Flashcards

1
Q

bipolar type 1

A

cycle between mania and depression

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2
Q

bipolar type 2

A

cycle between hypomania and major depression

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3
Q

cyclothymia

A

fluctuates between subsyndromal depressive and hypomanic episodes
2 years of symptoms

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4
Q

dysthymia

A

chronic sunsyndromal depressive episodes

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5
Q

what does FAST LANE stand for

A 
flight of idea
activity increased
sleep deprived but feels rested
talk increased
lability increased
attention decreased
narcissistic increase - think thyere the best
excessive increased
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6
Q

describe manic

A

greater than 1 week period
abnormally and persistently elevated mood
3 symptoms if elevated mood 4 if irritable
need for hospitalization may cuase harm

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7
Q

describe hypomania

A

at least 4 days
abnormal and persistenly elevated mood
no need for hospitalization but risk of going into mania

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8
Q

length of a mixed episode of major depressive and manic

A

greater than 1 week

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9
Q

what are rapid cyclers

A

4 or more episodes per year
harder to treat
poor long term prognosis
multiple mood stabilizers needed

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10
Q

risk factors to become a rapid cycler

A 
antidepressants - can precipitate mania 
stimulant use, even caffiene
hypothyroidism 
premenstrual period 
post partum period
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11
Q

acute mania can be precipitated by

A 
seasonal change
stressors
sleep deprivation
bright light
ECT 
antidepresants
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12
Q

what are depressive symptoms (DSIGCAPS)

A 
depressive mood
sleep inc/dec
interest decreased
guilt/worthlessness
energy decreased
concentration decreased
appetite decreased
psychomotor decreased
suicidal thoughts 
5 of these for 2 weeks
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13
Q

treatment goals

A 
shorten episode
decreased symptoms
restore function 
eliminate symptoms
prevent relapse
min AE of treatment 
educate and promote adherence
check drug interactions
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14
Q

agents for acute mania

A

typical antipsychotics - haloperidol, chlorpromazine for marked psychosis
benzos to manage symptoms right away
lithium or divalproex
combine with atypical antipsychotic in severe

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15
Q

agents for acute depression

A

lithium , quetiapine, lamotrigine
antidepressants
ECT

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16
Q

what benzo can be used chronically

A

clonazepam

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17
Q

which patients might not respond to lithium

A 
rapid cycling 
mixed states
comorbid conditions
secondary mania
substance abuse
absence of episodic bipolar illness in family
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18
Q

problems with anticonvulsants as mood stabilzers

A

delayed effectiveness acutely - use lorazepam
chronic prevention of relapse is poor
drug interactions common
CNS additive toxicity

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19
Q

most common AE for atypical antipsychotics

A

weight gain

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20
Q

order of meds to try for bipolar

A

lithium then
valproic acid then
atypical antipsychotics (olanzepine, risperidone, qutiepine)

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21
Q

first steps for bipolar treatment

A 
assess for secondary causes
discontinue antidepressants
taper off stimulants and caffiene
treat substance abuse
encourage good nutrition, sleep, exercise
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22
Q

treatment for acute mania

A

lithium, valproate or SGA plus benzo
antipsychotic for short term for agitation or insomnia
if non responsive try lithium + anticonvulsant + antipsychotic
if non responsive consider ECT if psychosis or add clozapine

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23
Q

why dont we generally use typical antipsychotics

A

lithium efficacy better
high incidence of mvoement disorders
may induce major depression

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24
Q

when can you use typical antipsychotics

A

acute mania very severe

discontinue once acute phase stabilized

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25
Q

treatment for acute depression

A

lithium first line
lamotrigine good for depression not as good for mania and titrated slowly
not evidence for addition of an antidepressant except
could try olanzapine and fluoxetine in severe

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26
Q

never combine _______

A

anitpsychotics

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27
Q

treatment of severe depressive episode

A

lithium or quetiapine
antipsychotic if psychosis
second carbamazepine or add antidepressant
third consider lithium + quetiapine or lamotrigine + antidepressant
fourth consider ECT

28
Q

expected mania symptom resolution with mood stabilzers

A

7 days

29
Q

expected depression symptom resolution with mood stabilizers

A

2-3 weeks up to 6

30
Q

treatment duration of acute mania

A

after remission continue with mood stabilizers
2-6mon: taper and discontinue adjunctive meds
discontinue mood stabilizer after 1 year if it was the first episode

31
Q

who requires lifelong treatment for acute mania

A

recurrent episodes
severe episodes
family hisotry
rapid onset mani

32
Q

treatment duration of depression

A

continue on mood stabilizer

continue antidepressant 6-12 weeks after remisiion then taper over 2-4 weeks

33
Q

how long does it take to reach steady state for lithium

A

4-5 days

34
Q

lithium dosage for chronic therapy

A

600-1800mg/day

35
Q

lithium dosage for acute

A

900-2400mg/day

36
Q

therapeutic concentration in acute mania target

A

.8-1.2mmol/L

37
Q

therapeutic concentration in chronic therapy target

A

0.6-1.2 mmol/L

38
Q

when is the best time to take a lithium target

A

morning sample pre am, 12 hour after post last evening dose

39
Q

how do you divide the lithium dose

A

into 2 or more divided doses

40
Q

factors that affect lithium steady state concentration

A

volume of distribution
clearance - renal function
drug interactions

41
Q

5 things to assess in lithium concentration

A 
take 12 hr after evening dose
divide dose into 2 doses
assess timing of doses in last 24hrs make sure has been taking
make sure at steady state concentration
assess clinical status
42
Q

how much should you increase the lithium dose in once daily dosing if the 12hr serum concentration is low

A

increase 10% if half life 40hr

increase 25% if half life 16hr

43
Q

why might you do once daily dosing

A

decrease urine volume

compliance

44
Q

when measuring steady state concentrations make sure the following are stable

A

compliance
renal function
volume status
drug interactions

45
Q

acute mania increases

A

clearance

increase dose to maintain level

46
Q

lithium monitoring

A 
effectiveness 
adherence 
volume, renal status 
serum concentrations
drug interaction 
toxic signs and symptoms 
chronic adverse effects
baseline: thyroid, BUN, scr, electrolytes, WBC, weight, pregnancy
47
Q

when should you monitor lithium serum concentration

A

initially 4-5 days

then every week until stable

48
Q

no need to monitor levels during chronic lithium therapy unless

A

to document compliance
signs of toxicity
drug interaction
change in renal function or volume status

49
Q

what increases lithium concentrations

A

nsaids
acei and arb
diuretics

50
Q

what decreases lithium concentrations

A

high sodium levels
theophylline
caffiene

51
Q

what increases neurotoxicity with lithium

A

antipsychotics
SSRI
carbamazepine

52
Q

lithium initial dose related adverse effects

A 
fine hand tremor 
GI 
mild polyuria, polydipsia
muscle weakness
cognitive impairment
53
Q

lithium moderate dose related adverse effects

A 
coarse tremor
GI upset
slurred speech
vertigo 
confusion
sedation, lethargy
hyperreflexia
54
Q

lithium severe dose related adverse effects

A

seizure
stupo
coma
CV collapse

55
Q

lithium chronic adverse effects

A

neurological - tremor, impaired memory, cogwheel rigidity
renal - nephrogenic diabetes insipidusm nephrotoxicity
t-wave changes, PVCs
hypothyroidism
leukocytes increased
weight gain
dermatologic - acne, rash

56
Q

initial dosage of valproic acid

A

500-750mg/day

5-10mg/kg/day

57
Q

usual dosage of valproic acid

A

1000-3000mg/day divided bid or tid

58
Q

therapeutic range of valproic acid

A

50-125mg/l

not well established for mood disorder

59
Q

metabolism of valproic acid

A

2C9

UGT

60
Q

valproic acid inhibitor of

A

2D6, 2C9, 2C19, UGT

61
Q

adverse effects of valproic acid

A 
sedation, lethargy 
NV, diarhhea
fine tremor
dizzy, unsteady
weight gain
alopecia 
thrombocytopenia, liver toxicity -- rare
62
Q

labs to monitor for valproic acid

A

levels at 2-4 days repeat every 5-7 until stable

TSH, T3, liver enzymes, CBC with diff and platelets, pregnancy, weight

63
Q

why do you introduce lamotrigine slowly

A

prevent rash and SJS

64
Q

risk for SJS in lamotrigine

A

gender
high plasma concentration
given with valproate
discontinue immediately

65
Q

common side effects of lamotrigine

A 
dizzy headach
diplopia
smonolence
ataxia
nausea
asthenia
66
Q

pharmacist role in an exacerbation

A 
rule out DI
optimize serum concentrations
check compliance
reinforce education 
good sleep hygiene
detect early symptoms of exacerbations

Clinical 2.0 winter (28 decks)

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