Bipolar affective disorder Flashcards
bipolar type 1
cycle between mania and depression
bipolar type 2
cycle between hypomania and major depression
cyclothymia
fluctuates between subsyndromal depressive and hypomanic episodes
2 years of symptoms
dysthymia
chronic sunsyndromal depressive episodes
what does FAST LANE stand for
flight of idea activity increased sleep deprived but feels rested talk increased lability increased attention decreased narcissistic increase - think thyere the best excessive increased
describe manic
greater than 1 week period
abnormally and persistently elevated mood
3 symptoms if elevated mood 4 if irritable
need for hospitalization may cuase harm
describe hypomania
at least 4 days
abnormal and persistenly elevated mood
no need for hospitalization but risk of going into mania
length of a mixed episode of major depressive and manic
greater than 1 week
what are rapid cyclers
4 or more episodes per year
harder to treat
poor long term prognosis
multiple mood stabilizers needed
risk factors to become a rapid cycler
antidepressants - can precipitate mania stimulant use, even caffiene hypothyroidism premenstrual period post partum period
acute mania can be precipitated by
seasonal change stressors sleep deprivation bright light ECT antidepresants
what are depressive symptoms (DSIGCAPS)
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
treatment goals
shorten episode decreased symptoms restore function eliminate symptoms prevent relapse min AE of treatment educate and promote adherence check drug interactions
agents for acute mania
typical antipsychotics - haloperidol, chlorpromazine for marked psychosis
benzos to manage symptoms right away
lithium or divalproex
combine with atypical antipsychotic in severe
agents for acute depression
lithium , quetiapine, lamotrigine
antidepressants
ECT
what benzo can be used chronically
clonazepam
which patients might not respond to lithium
rapid cycling mixed states comorbid conditions secondary mania substance abuse absence of episodic bipolar illness in family
problems with anticonvulsants as mood stabilzers
delayed effectiveness acutely - use lorazepam
chronic prevention of relapse is poor
drug interactions common
CNS additive toxicity
most common AE for atypical antipsychotics
weight gain
order of meds to try for bipolar
lithium then
valproic acid then
atypical antipsychotics (olanzepine, risperidone, qutiepine)
first steps for bipolar treatment
assess for secondary causes discontinue antidepressants taper off stimulants and caffiene treat substance abuse encourage good nutrition, sleep, exercise
treatment for acute mania
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
why dont we generally use typical antipsychotics
lithium efficacy better
high incidence of mvoement disorders
may induce major depression
when can you use typical antipsychotics
acute mania very severe
discontinue once acute phase stabilized
treatment for acute depression
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
never combine _______
anitpsychotics
treatment of severe depressive episode
lithium or quetiapine
antipsychotic if psychosis
second carbamazepine or add antidepressant
third consider lithium + quetiapine or lamotrigine + antidepressant
fourth consider ECT
expected mania symptom resolution with mood stabilzers
7 days
expected depression symptom resolution with mood stabilizers
2-3 weeks up to 6
treatment duration of acute mania
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
who requires lifelong treatment for acute mania
recurrent episodes
severe episodes
family hisotry
rapid onset mani
treatment duration of depression
continue on mood stabilizer
continue antidepressant 6-12 weeks after remisiion then taper over 2-4 weeks
how long does it take to reach steady state for lithium
4-5 days
lithium dosage for chronic therapy
600-1800mg/day
lithium dosage for acute
900-2400mg/day
therapeutic concentration in acute mania target
.8-1.2mmol/L
therapeutic concentration in chronic therapy target
0.6-1.2 mmol/L
when is the best time to take a lithium target
morning sample pre am, 12 hour after post last evening dose
how do you divide the lithium dose
into 2 or more divided doses
factors that affect lithium steady state concentration
volume of distribution
clearance - renal function
drug interactions
5 things to assess in lithium concentration
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
how much should you increase the lithium dose in once daily dosing if the 12hr serum concentration is low
increase 10% if half life 40hr
increase 25% if half life 16hr
why might you do once daily dosing
decrease urine volume
compliance
when measuring steady state concentrations make sure the following are stable
compliance
renal function
volume status
drug interactions
acute mania increases
clearance
increase dose to maintain level
lithium monitoring
effectiveness adherence volume, renal status serum concentrations drug interaction toxic signs and symptoms chronic adverse effects baseline: thyroid, BUN, scr, electrolytes, WBC, weight, pregnancy
when should you monitor lithium serum concentration
initially 4-5 days
then every week until stable
no need to monitor levels during chronic lithium therapy unless
to document compliance
signs of toxicity
drug interaction
change in renal function or volume status
what increases lithium concentrations
nsaids
acei and arb
diuretics
what decreases lithium concentrations
high sodium levels
theophylline
caffiene
what increases neurotoxicity with lithium
antipsychotics
SSRI
carbamazepine
lithium initial dose related adverse effects
fine hand tremor GI mild polyuria, polydipsia muscle weakness cognitive impairment
lithium moderate dose related adverse effects
coarse tremor GI upset slurred speech vertigo confusion sedation, lethargy hyperreflexia
lithium severe dose related adverse effects
seizure
stupo
coma
CV collapse
lithium chronic adverse effects
neurological - tremor, impaired memory, cogwheel rigidity
renal - nephrogenic diabetes insipidusm nephrotoxicity
t-wave changes, PVCs
hypothyroidism
leukocytes increased
weight gain
dermatologic - acne, rash
initial dosage of valproic acid
500-750mg/day
5-10mg/kg/day
usual dosage of valproic acid
1000-3000mg/day divided bid or tid
therapeutic range of valproic acid
50-125mg/l
not well established for mood disorder
metabolism of valproic acid
2C9
UGT
valproic acid inhibitor of
2D6, 2C9, 2C19, UGT
adverse effects of valproic acid
sedation, lethargy NV, diarhhea fine tremor dizzy, unsteady weight gain alopecia thrombocytopenia, liver toxicity -- rare
labs to monitor for valproic acid
levels at 2-4 days repeat every 5-7 until stable
TSH, T3, liver enzymes, CBC with diff and platelets, pregnancy, weight
why do you introduce lamotrigine slowly
prevent rash and SJS
risk for SJS in lamotrigine
gender
high plasma concentration
given with valproate
discontinue immediately
common side effects of lamotrigine
dizzy headach diplopia smonolence ataxia nausea asthenia
pharmacist role in an exacerbation
rule out DI optimize serum concentrations check compliance reinforce education good sleep hygiene detect early symptoms of exacerbations
