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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
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
26
never combine _______
anitpsychotics
27
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
28
expected mania symptom resolution with mood stabilzers
7 days
29
expected depression symptom resolution with mood stabilizers
2-3 weeks up to 6
30
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
31
who requires lifelong treatment for acute mania
recurrent episodes severe episodes family hisotry rapid onset mani
32
treatment duration of depression
continue on mood stabilizer | continue antidepressant 6-12 weeks after remisiion then taper over 2-4 weeks
33
how long does it take to reach steady state for lithium
4-5 days
34
lithium dosage for chronic therapy
600-1800mg/day
35
lithium dosage for acute
900-2400mg/day
36
therapeutic concentration in acute mania target
.8-1.2mmol/L
37
therapeutic concentration in chronic therapy target
0.6-1.2 mmol/L
38
when is the best time to take a lithium target
morning sample pre am, 12 hour after post last evening dose
39
how do you divide the lithium dose
into 2 or more divided doses
40
factors that affect lithium steady state concentration
volume of distribution clearance - renal function drug interactions
41
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 ```
42
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
43
why might you do once daily dosing
decrease urine volume | compliance
44
when measuring steady state concentrations make sure the following are stable
compliance renal function volume status drug interactions
45
acute mania increases
clearance | increase dose to maintain level
46
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 ```
47
when should you monitor lithium serum concentration
initially 4-5 days | then every week until stable
48
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
49
what increases lithium concentrations
nsaids acei and arb diuretics
50
what decreases lithium concentrations
high sodium levels theophylline caffiene
51
what increases neurotoxicity with lithium
antipsychotics SSRI carbamazepine
52
lithium initial dose related adverse effects
``` fine hand tremor GI mild polyuria, polydipsia muscle weakness cognitive impairment ```
53
lithium moderate dose related adverse effects
``` coarse tremor GI upset slurred speech vertigo confusion sedation, lethargy hyperreflexia ```
54
lithium severe dose related adverse effects
seizure stupo coma CV collapse
55
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
56
initial dosage of valproic acid
500-750mg/day | 5-10mg/kg/day
57
usual dosage of valproic acid
1000-3000mg/day divided bid or tid
58
therapeutic range of valproic acid
50-125mg/l | not well established for mood disorder
59
metabolism of valproic acid
2C9 | UGT
60
valproic acid inhibitor of
2D6, 2C9, 2C19, UGT
61
adverse effects of valproic acid
``` sedation, lethargy NV, diarhhea fine tremor dizzy, unsteady weight gain alopecia thrombocytopenia, liver toxicity -- rare ```
62
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
63
why do you introduce lamotrigine slowly
prevent rash and SJS
64
risk for SJS in lamotrigine
gender high plasma concentration given with valproate discontinue immediately
65
common side effects of lamotrigine
``` dizzy headach diplopia smonolence ataxia nausea asthenia ```
66
pharmacist role in an exacerbation
``` 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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